St Kizito Matany Moroto Diocese-Karamoja P.O. Box 46, Moroto - -

Annual Analytical Report Financial Year 2017/18

St Kizito Hospital Matany st 31 December 2018

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Endorsement of Report

This annual analytical report for St. Kizito Hospital Matany covering the period from 1st July 2017 to 30th June 2018 has been prepared by the Management of St. Kizito Hospital Matany. I endorse that it represents management’s views on the position of the Hospital in the period under report.

Br. Günther NÄHRICH ______

Chief Executive Officer of St. Kizito Hospital Matany

Date: 31st December 2018

This is to acknowledge that I have received this annual analytical report for St. Kizito Hospital Matany covering the period from 1st July 2017 to 30th June 2018. I have read it and endorse its authenticity and representativeness of the position of the Hospital in the year under report

Paul ABUL ______

Chairperson of the Board of Governors

Date: 31st December 2018

2of 108 TABLE OF CONTENTS

LIST OF ABBREVIATIONS AND ACRONYMS 4 ACKNOWLEDGMENT / APPRECIATIONS 5 IMPORTANT INDICATORS AND DEFINITIONS 8 EXECUTIVE SUMMARY 9 CHAPTER ONE, INTRODUCTION 11 THE HOSPITAL AND ITS ENVIRONMENT 11 THE COMMUNITY AND HEALTH STATUS 12 CHAPTER TWO, PRIMARY HEATLH CARE DEPARTMENT 17 A) CATCHMENT AREA 17 B) PERSONNEL STAFFING 18 C) ACTIVITIES / ACHIEVEMENTS 19 CHAPTER THREE, GOVERNANCE AND MANAGEMENT 28 ORGANOGRAM 28 THE BOARD OF GOVERNORS 29 MANAGEMENT 34 CHAPTER FOUR, HOSPITAL HUMAN RESOURCES 37 CHAPTER FIVE, HOSPITAL FINANCES 42 INCOME 42 EXPENDITURE 44 CHAPTER SIX, HOSPITAL SERVICES 51 A: OUT PATIENT DEPARTMENT 51 SPECIAL OPD CLINICS 54 HIV AND AIDS SERVICES 55 B: INPATIENT WARDS 62 ORGANISATION AND MANAGEMENT 62 MATERNITY WARD 65 C: OPERATING THEATRE 69 D: DIAGNOSTIC SERVICES 70 LABORATORY 70 IMAGING SERVICES 72 PHARMACY 73 CHAPTER SEVEN, HOSPITAL SUPPORT SERVICES 75 CHAPTER EIGHT, QUALITY AND PATIENT SAFETY 79 CHAPTER NINE, HEALTH TRAINING INSTITUTION 87 CHAPTER TEN, SUMMARY, CONCLUSION, RECOMMENDATION 97 FAITHFULNESS TO THE MISSION 97 ANNEX 1 - WITH HEALTH UNITS (Map) 104 ANNEX 2 - MEMEBERS OF BoG, HMT and NMTS STAT. COMMITTEE 105 ANNEX 3 - ANNUAL FINANCIAL REPORT 106

3of 108 LIST OF ABBREVIATIONS AND ACRONYMS

AIDS Acquired Immunodeficiency Syndrome ALOS Average Length of Stay ANC Antenatal Care ARV Anti Retroviral ART Anti Retro Viral Therapy BoG Board of Governor BOR Bed Occupancy rate CBOs Community Based Organisations CVD Cardio Vascular Disorder DHC District Health Committee DHO District Health Officer DHMT District Health Management Team DHT District Health Team DOTs Directly Observed Therapy EMOC Emergency Obstetric care EMTCT Elimination of Mother to Child Transmission ENT Ear Nose and Throat EPI Expanded Programme on Immunization FHW Field Health Worker FY Financial Year (July of previous year to June of the current year) GoU Government of Uganda GSM General Staff Meeting HBC Home Based Care HC Health Centre HCT HIV Counselling and Testing HIV Human Immunodeficiency Virus HMIS Health Management Information System HR Human Resources HSD Health Sub-District ICT Information and Communication Technology IGAs Income Generating Activities IMCI Integrated Management of Childhood Illnesses MCH/FP Maternal and Child Health Care/ Family Planning MDG Millennium Development Goal MH Matany Hospital MoU Memorandum of understanding MS Medical Superintendent NGO Non-Governmental Organisation N / MTS Nursing / Midwifery Training School NSSF National Social Security Fund OPD Out Patient Department OPM Office of the Prime Minister PEAP Poverty Eradication Action Plan PHC Primary Health Care PLWA People Living with HIV and AIDS SUO Standard Unit of Output SWOT Strengthen Weakness Opportunities and Threats TASO The AIDS Support Organization TB Tuberculosis UCMB Uganda Catholic Medical Bureau UDHS Uganda Demographic Health Survey UHSSP Uganda Health Sector Support Programme UNICEF United Nation Children Education Fund UNMHCP Uganda National Minimum Health Care Package VCT Voluntary Counselling and Testing VHT Village Health Team

4of 108 ACKNOWLEDGMENT / APPRECIATIONS

The Hospital Management Team on behalf of the Board of Governors of St. Kizito Hospital Matany wishes first of all to thank all the Hospital employees for their good team work and positive attitude toward their at times demanding and unrewarding work without which all what was achieved and described in this report would not have been possible.

ADMINISTRATION NURSING STAFF Br. Günther Nährich Administrator / CEO Atekit Helen Ag PNO Lokol Thomas Aquinas DHA & IT-Officer Sr. Nataline Mowo Principal Tutor Ogwango Samuelle Accountant Sr Gladys Licoru A D. Principal Tutor Lorot John Bosco Kapel Internal Auditor Sr. Anita Concept. Tutor Lomongin Emmanuel A/C Assistant Lomala Sarah Registered Nurse Otim David A/C Assistant Apolot Josephine Registered Nurse Nawot Monica Internal Cashier Amulen Rebecca Registered Nurse Ariam Juliana Assist Cashier Nabukwasi Sofia Registered Nurse Akurut Sylvia Assistant Cashier Among Mary Reg. Nurse Ngorok Magdalen Cashier Br. José Eduardo Diploma Nurse Loyep Stephen HR-Officer Adiao Grace Diploma Compr N Loput Johnson HMIS Officer Okello Eunice Diploma Nurse Amei Damiano HMIS/Data Mgt Assistant Ameo Jesca Registered N/M Nakiru Magdalen Secretary Amongin Celine Registered Midwife Namusungu Grace Office Attendant Asege Sarah Registered Nurse Akiteng Naome Secretary/NMTS Chemelli Nelly Registered Nurse MEDICAL OFFICERS Irusi Daniel Registered Nurse Dr John Bosco Nsubuga Gynaecologist, Med.Sup. Logwee James Registered Nurse Dr Kimuli Kasozi Surgeon Abucho Babrah Certificate Nurse Dr Borghi Emanuela Senior Medical Officer Loukae Gabriel Certificate Nurse Dr. John Ssembuusi Medical Officer Isone Mary Certificate Nurse Dr. Tapem Philip Medical Officer Okudet Paula Certificate Nurse Dr. Godfrey Kimbugwe Medical Officer Aloyo Agnes Certificate Nurse Dr Longora John Paul Medical Officer Adongo Anna G. Certificate Nurse PARAMEDICAL PERSONNEL Amoding Jennifer Certificate Nurse Oyaya Samuel Ochieng Senior Clinical Officer Nagendo Malisa Certificate Nurse Maraka Aloysius Clinical Officer Apio Loyce Certificate Nurse Awas Roseline Clinical Officer Okello Desderio Certificate Nurse Naggayi Sarah Clinical Officer Ocela Samuel Certificate Nurse Erau Faustine Clinical Officer Lomina Daniel Certificate Nurse Eboru Francis Anaesthetic Officer Asekenye Annet L. Certificate Nurse Obonyo Joseph Anaesthetic Officer Aguti Susan Certificate Nurse Amei Simon Peter Laboratory Technician Akiyai Margret Certificate Nurse Walter Ebong Laboratory Technician Ayalo Bena Certificate Nurse Bakar Fatuma Laboratory Technician Audo Esther Certificate Nurse Iluji Stephen Laboratory Technician Longoli Eric Certificate Nurse Atirok Abraham Laboratory Assistant Amuge Jane H. Certificate Nurse Modo David Laboratory Assistant Lotukei Anna Certificate Nurse Losike Henry Laboratory Assistant Amoding Harriet Certificate Nurse Kodet Andrew Laboratory Assistant Abinyo Eunice Certificate Nurse Locham Augustine Ophthalm. Assistant Mutonyi Linda F. Certificate Nurse Awas Patrick Othopedic Officer Ajalo Catherine Certificate Nurse Apono Mark Physiotherapist Lokwii Monica Certificate Nurse

5of 108 Logiel Kizito Certificate Nurse Namoe Rose Assist. Store Keeper Lolem John Certificate Nurse Alumo Luigina Assist. Store Keeper Lokubal Albino Certificate Nurse Santina Yeno Assist. Store Keeper Abura Moses Certificate Nurse Akol Sarah G/S Cleaner Acom Rita Certificate C. Nurse Adupa Janet Cleaner Adela Jesica Florence Certificate C. Nurse Aboka Agnes Cleaner Opus Stephen Certificate C. Nurse Aisu Anna Cleaner Anyuu Night Grace Certificate Midwife Chero Anna Cleaner Anyait Kesia Rose Certificate Midwife Ngorok Scola Cleaner Longora Anna Certificate Midwife Kiyonga Agnes Cleaner Aliat Esther Certificate Midwife Lokoryo Dorothy Cleaner Lotukei Anna Grace Certificate Midwife Longole Theresia Cleaner Nakiru Lucy Certificate Midwife Lopwanya Veronica Cleaner Napeyok Paulina Certificate Midwife Napeyok Lucy Cleaner Aleper Esther Certificate Midwife Alinga Vicky Cleaner Awoyo Immaculate Certificate Midwife Neno Betty Cleaner Okuvuru Victoria Certificate Midwife Akol Alice Cleaner Mazapke Sidonia Certificate Midwife Lomongin Clementina Cleaner Ayoo Sarah Certificate Midwife Agilu Evalyn Cleaner Akol Proscovia Certificate Midwife Akung Betty Cleaner Achia Agatha Certificate Midwife Longoli Maria Cleaner Achia Christine Certificate Midwife Kodet Magdalen Cleaner Lomilo Paul Dental Attendant Abura Alice Cleaner Lotukei Josephine Assistant Counsellor Achilla Lucy Cleaner Dengel Margret Assistant Counsellor Achia Giovanna Cook Otyang Charles Nangiro Dark Room Att. Alinga Amalia Cook Lotukei Anjello Dark Room Att. Akello Beatrice Cook Adiaka Rosemary Nursing Assistant Logiel Agnes Cook Agaro Sylvia Nursing Assistant Apuun Lucy Cook Akinyi Jennifer Nursing Assistant Ngole Jacinta Cook Akol Lucy Nursing Assistant Amuron Hellen Cook Awas Mary Goretti Nursing Assistant Angella Magdalen Cook / Caterer Jaka Valentine Nursing Assistant Lokoel Agnes Cook Karane Josephine Nursing Assistant Nake Cecilia Cook Lochoro Hellen Nursing Assistant Aleper Dina Cook Sagal Florence Nursing Assistant Nauga Cecilia Cook Keem John Senior Nursing Aid Longok Valentine Cook Akumu Lucy Senior Nursing Aid Ojao Angelline Cook Nachuwa Mary Senior Nursing Aid Aledo Paska Cook Yeno Maria Senior Nursing Aid Lotukei Agnes A. Pastoral Care Giver Anero Betty Nurse/Aid, TB Ward Kedia Pasqualle Pastoral Care Giver Achuka Angelina Nurse/Aid, OPD Pulkol John Laundry Attendant Kodet Jenifer Nurse/Aid, OPD Lokiru Raphael Laundry Attendant Namoe Margaret Nurse/Aid, Maternity Aleper Emmanuel Incinerator Attendant Amodoi Josephine Nurse/Aid, CHW Akol Joseph L. Watchman Epur Scholastica Nurse/Aid, Medical Angolere Mario Watchman Logiel Rose Nurse/Aid, TB Ward Lochuge Francis Watchman Logiel Mary Nursing Assistant Koryang Isaac Watchman Namer Christine Nursing Assistant Muya Richard Watchman Aleper Agnes Theatre Attendant Lochoro Maxson Watchman SUPPORT STAFF Lomeri John Compound Atim Magdalen Ag Store Keeper Losur Stephen Compound

6of 108 Teko Peter Compound Iriama Philip Mechanic / Driver Lochan Matteo Compound Lemuya Markson Hub Rider Lokol Enok Compound Omaswa Francis Mechanic / Driver Lokut Marko Compound Owilli Silvio Mechanic / Driver Longoli Simon Compound Sagal Samuel Joel Mechanic / Driver Lodungokol Marco Compound Lokut Matthew Mech / Metal W / Driver Keem Marco Compound Longole Pascal Mechanic Lomilo Simon Compound Lorika Emmanuel Mechanic Ichumar Peter Mortuary Attendant Lokiyo James Metal worker Lobur Joseph Mortuary Attendant Aleper Gabriel Plumber / Mason Achia Anna Tailor Olupot John J Plumber Lolem Lucy Tailor Okidi Martin Senior Plumber Nakong Lucy Assist Tailor Lokiru Peter Porter Loma Alice Tailor Loburo Peter Porter Ojara Joseph Agric.Proj. Implementor Ngorok Eliya Porter TECHNICAL DEPARTMENT Amei Domenic Casual Worker Bruno Frank In charge Loli John Casual Worker Teko Raphael Procurem Advisor, S. Driver Loteng Philip Casual W. / Forest Achilla Matthias Carpenter Lotukei Michael Casual Worker Lokwii Joseph Carpenter Logiel Pasquale Store Keeper Sagal Michael Carpenter Lochen Sisto Support Staff Eliau Julius Electrician / Driver Iiko Michael Support Staff Okwii Mathew Electrician Lowakori Marko Support Staff Otyang Paul Electrician/Metal Worker Ngorok J.B Support Staff Logiel Thomas Mason Moru Paul Support Staff Lokiru Mark Mason PUBLIC HEALTH DEPARTMENT Mubakye Patrick W Mason Achia Deborah Incharge PHC / SNO Lajul Robert Mason Lowanyang Lucy N PHC Supervisor Loit Abraham Mason Ngiro Martin Health Educator Lotee Paul Mason Lokwang Anthony Health Inspector Lomongin Daniel Mason Alinga Mary Gina Vaccinator Mudong Martina Vaccinator

We do remember all those who help us in sustaining our health services from near and far (our benefactors) with spiritual and material resources. In particular we thank the two Italian Matany support groups: Gruppo di Appoggio dell’Ospedale di Matany-ONLUS from Milano and Associazione Toyai – Onlus from Pavia. We further thank the Government of Uganda, CUAMM; The Italian Cooperation; Insieme Si Puo from Belluno; ‘IDEA Onlus’ from Torino; PMK Aachen, DKA Wien, MIVA/BBM Austria, Horizont 3000, STACC Scotland, Sign of Hope, Diocese of Rottenburg-Stuttgart, Dr. Keith with Eye Team; the Comboni Missionaries and Comboni Sisters, Dr. Friedrich Ullrich, and SES Bonn, Thomas Kummich and so many not mentioned but surely valuable supporters, who have helped Matany a lot in different ways.

We thank those involved in making policy decisions in favour of the smooth running of our Institution. A special thanks to the Uganda Catholic Medical Bureau, for all its support and encouragement over the past years.

We exercise our services under the mandate of the Ugandan Government and in particular the Ministry of Health for the Hospital, Ministry of Education for the Training School, professional bodies, Uganda Catholic Medical Bureau, Moroto Diocesan Health Office and other statutory bodies.

Our special vote of thanks goes to the numerous patients who have availed us with an opportunity to follow in the footsteps of Christ, to bring healing to the sick and suffering. We thank all our staff, our students, our expatriates and all the Ugandans who continue to make St. Kizito Hospital for what it is known for - a model for dedicated and compassionate service.

7of 108 IMPORTANT INDICATORS AND DEFINITIONS

1. Inpatient Day / Nursing Day / Bed days = days spent by patients admitted to the health facility wards. 2. Average Length of stay (ALOS) = Sum of days spent by all patients/number of patients = Average length of days each in-patient during each admission. The actual individual days vary. 3. Bed Occupancy Rate expressed as % = used bed days/available bed days = Sum of days spent by all patients/365 x No. of beds =ALOS x No. of patients/365 x No. of Beds 4. Throughput =Average number of patients utilising one bed in a year =Number of patients/no. of beds 5. Turn over interval =Number of days between patients = (365 x no. of beds)-Occupied bed days/no. of patients 6. FSB (Fresh Still Birth): This is a baby born with the skin not pealing / not macerated. The foetal death is thought to have occurred within the 24 hrs before delivery. However it is important for us to know the trend of deaths of foetuses actually occurring in mothers who have arrived already in the hospital (Foetal heart sound heard on arrival). For this purpose we shall monitor FSB in total as well as FSB of fetuses who died in hospital. They have been separated in the table. The hospital should try to provide space to collect this information from the maternity ward / delivery room. 7. Post C/S Infection Rate: = (No. mothers with C/S wounds infected / Total No. of mother who had C/S operations in the hospital) x 100. = The rate if caesarean section wounds getting infected. It is an indicator of the quality of post-op wound care as well as pre-op preparations. 8. Recovery Rate: = % of patients admitted who are discharged while classified as “Recovered” on the discharge form or register. = (No. of patients discharged as “Recovered” / Total patients who passed through the hospital) x 100 9. Maternal Mortality Rate (for the hospital): = Rate of mothers admitted for delivery and die due to causes related to the delivery = (Total deaths of mothers related to delivery / Total number of live deliveries) x 100 10. SUO = Standard Unit of Output. This is where all outputs are expressed into a given equivalent so that there is a standard for measurement of the hospital output. It combines Outpatients, Inpatients, Immunisations, deliveries, etc which have different weights in terms of cost to produce each of the individual categories. They are then expressed into one equivalent. As the formula is improved in future it may be possible to include Out-patients equivalence of other activities that may not clearly fall in any of the currently included output categories. 11. SUOop = SUO calculated with inpatients, immunizations, deliveries, antenatal attendance, and outpatients all expressed into their outpatient equivalents. In other words, what would be the equivalent in terms of managing one outpatient when you manage e.g. one inpatient from admission to discharge? SUO-OP = (15 x no. IP) + (no. OP) + (5 x no. deliveries) + (0,2 x no. of immunizations given) + ( 0,5 x ANC visits) 12. TB case notification rate = total cases of TB notified compared with the expected number for the population in one year =Total cases of TB Notified / Total population x 0.003. 13. OPD Utilisation = Total OPD New attendance in the year / Total population of the area.

8of 108 EXECUTIVE SUMMARY

Description of the Hospital and its environment

St. Kizito Hospital Matany is located within Napak District in North-Eastern Uganda, bordering the East side, Katakwi and Amuria, districts to the West, Nakapiripirit to the South; Kotido and Abim Districts to the North.

Due to the periodic drought the entire Karamoja Region is always at risk of famine. The major challenges for health care delivery are: very poor health seeking behaviour, the poor road network, hard to reach settlements and the irregular telephone network coverage. Functionally the Hospital is a de facto regional referral health facility for the entire Karamoja Region including the neighbouring Districts of Teso (Amuria, Katakwi, ), and deals with an average annual admissions of about 10,000 inpatients and 26,000 outpatient consultations.

The Hospital holds a significant public health influence in the catchment’s population and is linked to fourteen peripheral Health Units in Bokora Health Sub-District; serves as an administrative headquarters where planning, implementation, monitoring and evaluation of all PHC activities are done. The socio-economic impact of the Hospital to the immediate surrounding community is quite evident by a fast growing and busy Matany Town Board.

The Hospital entirely depends on the inhabitants of this Trading Centre for its support staff and most of its skilled labourers, thus not only providing employment opportunity to the community but also creates a symbiotic co-existence between the Hospital and its neighbourhood as well as a sense of ownership of the Hospital facility and its services by the community.

The functionality of Matany Hospital is in accordance with the National Hospital policy of the Republic of Uganda with technical guidance from the Uganda Catholic Medical Bureau (UCMB) as well as Napak District Health Office, local authorities, and other partners in the Health sector (including the service beneficiaries).

The Hospital capacity constitutes 250 beds distributed through /, Internal Medicine, Tuberculosis, Paediatrics and Surgery Departments. Other services provided by the Hospital include: Diagnostic Laboratory, diagnostic imaging, General surgery, Orthopaedic and Physiotherapy, Counselling, HIV/AIDS Clinic, Antenatal Clinic and Prevention of Mother to Child Transmission, human resource development to meet the Hospital needs. Annexed to the Hospital are a Health Training Institution, a Human Resource Development Centre and an Airstrip.

The Nursing and Midwifery Training School has an annual intake of 15 UCN students and 20 UCM students with slight variations.

A well established Technical Department with construction department for general repairs and maintenance of the Hospital’s equipments, plants and infrastructures is another important element of the Hospital, generating also income through service to the public.

The Hospital for its effectiveness in administration and daily operation developed key documents to guide the management in the day to day running of the institution. Human resource and finance manuals were developed and are currently in use. Other aspects in the health professional development involves nursing students, midwives, clinical officers, internship training for paramedical students, medical technologists and others, are conducted within the Hospital. The Hospital is contributing to the health manpower development in Uganda.

9of 108 Achievements / improvements that have been made in FY 2017/18

Key planned activities Status of achievement Continue with the SLAMTA program to The Hospital Laboratory has remained at star 2. achieve star 3 Mentorship had been inadequate.

3 Pharmacy Assistants, 2 Theatre Assistants, 5 Diploma Nurses / Midwives returned after the completion of their trainings. One surgeon is Continuous Staff Development - for completing his training in Jul 2018. Other cadres various cadres continue or commenced their training, e.g. 1 Surgeon,1 Medical Officer, 4 Diploma Nurses, 1 Laboratory Technician

Start the Electronic Patients’ Records Preparations to start the EPRMS were done. First Management System in the first half of phase to operationalise the system in OPD has been FY 2017/18 achieved.

Conducted in October and November 2017 in Conduct second cervical cancer screening selected Sub Counties in Napak District. in the Hospital and the catchment area 703 women were screened

Only one dormitory block was renovated and a rain Continue major renovation of NMTS if harvest system installed. Also the sewerage system funds are made available was overhauled. The pledged funds from OPM arrived in Feb 2018.

Overhauling of the water piping system in Most components of the project have been the Hospital with installation of two new implemented within the Financial Year. water tanks a' 50,000 litres. Install a fire Some components for the Fire fighting system need fighting system in the Hospital with water to be completed in FY 2018/19. hydrants at strategic points

Building of new toilet and shower block in This activity will be completed in FY 2018/19 the staff quarters

Two representatives from Milano Support Group New staff house with six units came for the inauguration on 1st November 2017.

Procurement/Donation of new Ambulance Ambulance was received in September 2017

Renovation of old Patient Attendants Kitchen which was turned into an Archive Completed and will soon be put in use and IT-Store

Goats were bought in May 2018 in view of supplying Purchase of some Dairy Goats goats' milk to the Nutrition Unit of the Hospital

Renovation of TB ward patients’ Completed bathrooms and toilets

Renovation of Technical department Still in progress

Important recommendations/plans for the coming year 2018/19

 Continue with the SLAMTA program to achieve star 3

 Continuous Staff Development - for various cadres  Scale up the Electronic Patients’ Records Management System by linking up Special Clinics with OPD

10 of 108 Important recommendations/plans for the coming year 2018/19 (continued)

 Conduct third cervical cancer screening in the Hospital and catchment area

 Opening up of a youth corner to offer youth friendly health services

 Continue major renovation of NMTS if funds are made available

 Complete installation of fire fighting system in the Hospital.

 Complete Building of a new toilet and shower block in the staff quarters  Putting up a second greenhouse with drip irrigation with surrounding vegetable beds for Hospital kitchen, staff and NMTS kitchen  Acquisition of a second Carestream (to convert X-ray images into digital images)

 Renovation of the NMTS Library by raising the building one meter

 Purchase of a Washing Machine

 Purchase of an Incinerator

 Acquire a new vehicle for PHC activities

 Connect Staff Quarters to Electricity Grid

 Expansion of patients’ laundry area

11 of 108 CHAPTER ONE

INTRODUCTION

The Hospital and its environment

St Kizito Hospital Matany is a Private Not-For-Profit (PNFP) institution with social and spiritual objectives, belonging to the Catholic Diocese of Moroto (North-Eastern Uganda). It was built at the beginning of the 70’s with the help of MISEREOR (a German Church Organisation) on request of the Comboni Missionaries in Uganda, and has since then provided a very essential comprehensive package of health services to the population of the Karamoja region, an extremely remote and underdeveloped region of the Country characterised by very poor health indicators. By its functional profile, Matany is a General Hospital with a bed capacity of 250 distributed through Obstetrics/Gynaecology, Internal Medicine, Tuberculosis, Paediatrics and general Surgery Departments. ` Other services provided by the Hospital include: Diagnostic Laboratory, diagnostic imaging, General surgery, Orthopaedic and Physiotherapy, Counselling, HIV/AIDS Clinic, Antenatal Clinic, Prevention of Mother to Child Transmission (PMTCT) and human resource development to meet the Hospital needs. Annexed to the Hospital is a Nursing and Midwifery Training Institution, a Human Resource Development Centre and an Air Strip. Although Ministry of Health has upgraded Moroto Hospital into a regional referral hospital, Matany Hospital still shoulders the burden of heavy workload due to patients’ preference to seek its services. Also, due to its relatively well developed and maintained infrastructure and above average quality and affordable services provided by committed staff, Matany Hospital still serves as a referral health facility for the entire Karamoja Region including the neighbouring Districts of Teso (Amuria, Katakwi, Soroti). The total number of admissions for the year under review was 9,927 In-patients with an increase of 24 patients as compared to the previous year, and the total new and re-attendant outpatient consultations during the FY were 25,847 showing an increase of 7.6% as compared to the previous year. In the special Clinics of the Hospital 64,497 patients were seen and thus the total of all out patient contacts was 88,076 compared to 87,603 which constitutes an increase of 0.5%. Deliveries in the Hospital have increased by 122 (10.5%), as well as antenatal attendance by 364 (10.3%), with more staff allocated to the clinic and increased health education. More men accompany nowadays their wives for this service. Total immunisations has increased by 1,674 (3.6%). The Public Health demands on the Hospital are becoming more challenging and costly. Although the government gives subsidy to the Hospital in form of delegated PHC funding, less attention has been taken on the sky-rocketing market prices of medicines and supplies! The number of peripheral health units for support supervision has increased to 14 and the District Local Government has recommended the establishment of more lower level health units. As much as Matany Hospital would wish to play a significant public health role in the catchment’s population, the cost implications of this task need to be taken into consideration. The PHC Department serves as an administrative headquarters for Bokora Health Sub- District (HSD) where planning, implementation, monitoring and evaluation of all PHC activities are done. The socio-economic impact of the Hospital to the immediate surrounding community is quite evident by a fast Matany town. This lively economic focus in our Health Sub District is a daily convergence point of the community with great influence on the economic and social aspects in Bokora. It caters for all needs of the residents, patients, attendants and visitors.

12 of 108 Due to financial constraints and with the introduction of the VHTs the Hospital Administration had to depart from its Field Health Workers, after informing the District Health Office, by 31st December 2014. The impact of their missing services, especially immunisations, will have to be evaluated in due course. The Hospital entirely depends on the inhabitants of this Trading Centre for its support staff and a good number of skilled labourers, thus not only providing employment opportunity to the community but also creates a symbiotic co-existence between the Hospital and its neighbourhood as well as a sense of ownership of the Hospital facility and its services by the community. The role played by the Hospital in the socio-economic transformation of the surrounding residents cannot be under-estimated. This contribution is done through salary payments to the staff, vocational training to the youth and scholarship/bursary support to students. The functionality of Matany Hospital is in accordance with the National Health policy of the Republic of Uganda with technical guidance from the Uganda Catholic Medical Bureau (UCMB) as well as Napak District Health Office, Board of Governors, and other partners in the Health Sector (including the service beneficiaries). The current Board of Governors underwent an induction exercise in April 2018 by UCMB on the statutory role of overseeing functionality of the Hospital.

The geographical location of Napak District with Health Units is found in the Annex 1

The community and health status

Napak District is inhabited by the Bokora sub ethnic group of the Karimojong tribe. The other groups i.e; Matheniko, Jie, Dodoth, Pokot, Pian, Ik and Kadam comprise the inhabitants of the rest of the other six Districts of Karamoja Region. The socio-economic organisation of the community has significant influence on the health status and indicators. The people live in homestead clusters called "ere" (Karimojong- homestead), comprising of relatives, friends and kinsmen. For security reasons each ere has a thorn fence with residential family clusters living all around. A central place right in the centre of every homestead is the kraal. This is the most protected part of the homestead where cows, goats, sheep and donkeys live. A village may have up to 400 inhabitants.

People live in small and short round huts with mud walls and grass thatched roofs. The huts are used mainly for sleeping and during the night up to 10 people can fill it. The average sleeping arrangement for each family is in three groups (i.e. adults/parents, adolescents and children) sharing a small hut. Such practices coupled with poor ventilation, lack of sanitation facilities, limited access to clean and safe water, living in close proximity to livestock and general poor health seeking behaviour of the community makes it easier for the spread of communicable and hygiene related diseases like scabies, diarrhoeas, eye infections, TB, other RTIs, and zoonotic diseases etc.

The Karimojong socio-economic organization is mainly agro-pastoralists. There exist some agricultural potentialities, especially around Iriri, Apeitolim, Nakapiripirit and Abim where the land is fertile and the rainfall pattern fairly reliable. The main crop cultivated is sorghum and few other cereals. The Karimojong population lives in both static and nomadic communities, the elderly stay in the villages while the youth roam the plains in search of pasture and water for the livestock, both communities reunite in the rainy season lasting March to September, the rain pattern in the region is significantly changing and becoming more unpredictable, with prolonged draught spells subjecting the community to chronic famine and high levels of malnutrition among the under 5. This nomadic lifestyle makes health services and other social services delivery quite difficult especially for the mobile proportion of the population.

13 of 108 Although polygamous lifestyle is not a cultural norm among the Karimojong tribe, this practice is quite common and has its importance rooted onto the prestige associated with large family size. Rural-urban migration has overwhelmingly contributed to the rising HIV/AIDS prevalence in the region though relatively low compared to other regions in the country. Participation of men in socio economic welfare of their families still leaves a lot to be desired. Women play a very significant role in family up-keep and welfare; moreover men control family resources and are the decision makers! This makes women and children more vulnerable to domestic violence and neglect.

Small arms proliferation with associated insecurity in the region over the last three decades has had a negative impact on the peace and development programmes in Karamoja. However; the disarmament programme initiated by Government some years back has restored peace and rule of law in the region. It is now possible to travel for medical outreaches to distant places without carrying military escorts.

Napak District has one Health Sub District: Bokora HSD, which is designated under the Hospital support supervision. Matany Hospital is heading Bokora Heath Sub District which has seven Sub-Counties and a total of 42 parishes with 250 villages. The recent Census revealed a much lower population than projected in previous years.

Table 1.1: Demographic data for the catchment area compared to HSD and District

Catchment Area Population Group Formulae Matany Sub- HSD District County Total population (projected A 23,734 153,971 153,971 for the year under report) Total expected deliveries B (5/100) * A 1,187 7,699 7,699 (5% of population) Total Assisted deliveries in C 1,354 4,745 4,745 Health Facilities Tot. Assisted deliveries as D (C/B)* 100 114% 62% 62% % of expected deliveries E Children <1 year (4.3%) (4.3/100) * A 1,021 6,621 6,621 F Children < 5 years (20.2%) (20.2/100) * A 4,794 31,102 31,102 Women in child - bearing G (20.2/100) * A 4,794 31,102 31,102 age (20.2%) H Children < 15 years (46%) (46/100) * A 10,918 70,827 70,827 I Orphans (10%) (10/100) * A 2,373 15,397 15,397 Suspected tuberculosis in J (A) * 0.003 71 462 462 the service area

Table 1.2 TOP TEN CAUSES OF OPD ATTENDANCES IN BOKORA HSD FY 2015/16 FY 2016/17 FY 2017/18 Malaria 27,846 Malaria 49,725 Malaria 49,123 Pneumonia- cough RTI 15,071 Pneumonia 33,851 34,645 or cold Mild acute Mild Acute Mild Acute 3,046 7,858 7,285 Malnutrition (MAM) Malnutrition (MAM) Malnutrition (MAM) Diarrhoea acute 2,834 Diarrhoea-Acute 6,470 Diarrhoea 6,075 Urinary Tract Pneumonia 2,301 3,640 GID (non-infective) 4,932 Infections (UTI) Other eye Urinary Tract Eye conditions 2,025 3,151 4,307 Conditions Infections (UTI)

14 of 108 FY 2015/16 FY 2016/17 FY 2017/18

GID 1,917 GID (non-infective) 3,090 Pneumonia 4,285 Other eye Urinary tract Infect. 1,787 Injuries (All types) 2,975 3,918 Conditions Skin diseases 1,715 Skin Diseases 2,781 Injuries (All types) 3,906

Injuries 1,631 Intestinal Worms 2,404 Skin Diseases 3,757

Graph 1.1: Top 10 diseases in Bokora Health Sub District during FY 2017/18

Malaria is still the leading cause of OPD attendance over the years. However numbers of out patients has slightly decreased over this FY 2017/2018 which we attribute to increased work done by the VHTs to treat common illnesses like diarrhoea, fever and cough at household level. There was an increase of 3.9% in malaria testing using rapid diagnostic tests and blood side for malaria in FY 2017/18. This has improved in excluding a sizeable number of cases that were usually considered to be having malaria clinically. There are also more small private clinics and drug shops opened where it is presumed that patients also seek services from there. The migration of the communities to the fertile areas where there are no social services resulting in limited accessibility to the health units also contributes to this reduction. Compared to the top ten causes of OPD attendance in FY 2017/2018 less progress has been made in tackling malnutrition in the Health Sub District with improved screening of malnourished children at health facility making mild acute malnutrition (MAM) among the top three causes of OPD attendance.

Public health surveillance is the mechanism that Matany Hospital PHC department uses to monitor the health status of the catchment communities. Its purpose is to provide a factual basis from which the Hospital can appropriately set priorities, plan programs, and take actions to promote and protect the public’s health.

Given the public health role played by Matany Hospital in management of health services at the HSD, disease surveillance is a routine exercise both at the community and health facility level. The Ministry of Health Case definitions for each of the epidemic prone diseases are strictly observed for disease detection. Also the procedures for notification of such diseases to the District and Ministry of Health are followed in case of any notifiable events. Weekly surveillance reports are submitted to the District Health Office, MoH and WHO field office in Moroto, using the HMIS form 033b. Common diseases

15 of 108 epidemic events reported in the weekly surveillance reports include; malaria and dysentery. Occasionally there are challenges in timeliness and completeness of the surveillance reports from lower level health facilities and efforts are being made to ensure that this problem is overcome by frequent submission reminder to the Health Unit in charges.

Other factors influencing the health status of the community include, high levels of illiteracy, poverty and poor health seeking behaviour of the community. Over time, there has been some observed improvement in the general health status of the community, including the immunisation coverage.

Reproductive Health (RH) indicators are still quite poor in Karamoja and are characterised by: low 4th ANC attendance and low TT coverage for WCBA. Supervised deliveries are at 62%. There are continued efforts through community dialogue and health education to improve RH indicators in the HSD.

16 of 108 CHAPTER TWO

HEALTH POLICY AND DISTRICT HEALTH SERVICES

PRIMARY HEALTH CARE DEPARTMENT (PHC)

A) Catchment area

The Health Sub District central role is the delivering of Uganda National Minimum Health Care Package through health units under its jurisdiction and the community health department of Matany Hospital doubles as Bokora Health Sub-District office as well implementing health activities in accordance to the health sector strategic plan set by the Ministry of Health with a purpose of achieving improved health for all in the HSD. The Community Health Department continues to offer basic preventive, promotive and curative care and provide support supervision of the community through health centres and village health team members under it.

Bokora Health Sub-District comprises of 8 Sub-Counties (i.e. Matany, Iriri, Lokopo, Lopei, Ngoleriet, Lotome, and Lorengecora including one town council Located in Lorengecora. It was in July 2010 that Napak District was curved out of Moroto District which covers the area of Bokora HSD. There are 14 Health Units, 1 Hospital (Matany), 6 health centre IIIs (Iriiri, Lorengechora, Lopeei, Lokopo, Kangole and Lotome) and 7 health centre IIs (Amedek, Nabwal, Morulinga, Ngoleriet, Namendera, Nakicumet, Kalokengel and Apeitolim) are contributing to improved health services to the communities.

Although significant progress has been made over the years, Health Sub District key challenge has been no funding for Namendera, Nakicumet for the last three financial years and the new health centre of Kalokengel Health Centre II in Lotome Sub County. These health centre IIs don’t receive medicines and primary health care recurrent non-wage since they were created by the district at the time when Government had put in place a ban on creation of more health centre II’s and they have been depending on what the HSD could borrow from other health units. The district council had endorsed the opening of more two new health centre II’s in FY 2017/2018 that is Naturumurum in Iriiri and Lokitedet in Matany Sub County however they stalled due to the problems the other three health units are grappling with. Communities in hard to reach settlements continue to experience a number of interconnected challenges including lack of educational facilities, nearby health centre, few water points, poor road network that makes this places inaccessible during rainy season among others. Nakayot settlement remains to be one of the unattended priorities yet rapid increase in population continues. Besides that the area is still a place of conflict between wild life authority and the settling communities. A community Based Organization, Clide is still continuing to offer a few minimum basic services that is more of a drop in the ocean and has a small structure there where the HSD used to have a fridge for vaccines but its maintance posed a challenge due to logistical support and rainy season. The suggestion to have this place supported as an Aid post to treat simple conditions still remains food for thought since it would make a desired difference compared to doing nothing. The elevation of Iriri health centre 111’s to four is a long time proposal that has not been implemented however it is proposed that to be considered in the national budget financial year 2018/2019 as one among the four health centres in Karamoja region to be upgraded. The plan if realised would be a big boost the district health services given the fact that 1/3 of the district population is found there.

17 of 108 Matany Hospital and Kangole Health centre are Private Not for Profit health units under UCMB which offer services at highly subsidised prices compared to other PNFPs in the country.

There is evident presence of good health care but other factors such as high illiteracy rate, lack of business and working opportunities, poverty with high consumption of Waragi, poor climatic conditions and long distances walked particularly in hard to reach to receive health care still remain a challenge in Health care provision and a setback in achieving sustainable development goals. It is also sad to note that prostitution is found in Matany trading centre which is now upgraded to a town council. This could lead to increase of sexually transmitted diseases including HIV/AIDS, alcoholism, violence etc…..

Table 2.1: Health Centres for support supervision by Matany Hospital in Bokora HSD

Sub Distance from Catchment Health Units Counties Matany Hospital Population 1. Matany Hospital Matany 2. Morulinga HC II 8 km 23,734 3. Nakicumet HC II 18 km 10 km ( 21 Km during 1. Lokopo HCIII Lokopo the rainy season) 22,595 80 km (120 km during 2. Apeitolim HC II the rainy season)

1. Nawaikorot HC II 15 km Ngoleriet 18,880 2. Kangole HC III 10 km 17 km (50 km during Lotome Lotome HC III 12,288 the rainy season)

1. Iriri HC III 45 km 2. Nabwal HCII 70 km Iriiri 44,460 3. Amedek HC II 53 km 4. Namendera HC II 78 km 11 km (37 km during Lopeei Lopeei HC III 14,201 the rainy season)

Lorengecora 1. Lorengecora 37 km 11,767

2. Lorengecora T.C 37 km 5,595 Total Bokora HSD 153,971

Table 2.2: Population figures for year 2017/2018: (Bokora HSD population from Census 2014, total population NAPAK DISTRICT = Bokora Health Sub-District = 153,971 at growth rate of 1.9)

% of the Age group Target Population Remarks population For DPT-HEP B + Hib, Infants < 1 Yr. 4.3% 6,621 measles, polio coverage Children < 5 Yrs 20% 30,794 For Polio campaign (NIDs)

Women 15 to 49 Yrs 23% 35,413 For TT coverage

Pregnant Women 5% 7,699 For TT coverage

>6 months to <5 years 19.2% 29,562 For Child days 1 – 15 years 48.4% 74,522 For child days

18 of 108 B) Personnel/Staffing  Matany Hospital Primary Health Care Department

The Primary Health Care Department (PHC) is fortunate to receive funds from delegated funds of the hospital and has preferential allocation of necessary human resource for health from the district and the hospital that comprises a team of eight established staff at the HSD office: 1 Medical Officer (the in charge of the HSD), 1 Bachelor Nurse, 1 Public Health Nurse, 1 Health Educator, 1 Health Inspector, 1 Health Information Assistant, 1 Ophthalmic Assistant, 1 Nursing Assistant and 2 Counsellors (one Registered Nurse and one Nursing Assistant). At the community level there were up to 31st December 2014 Field Health Workers (FHWs) that assisted the health workers carry out immunisations. Due to financial constraints the hospital does not employ them now but respective health units have continued to work with some of them. Matany Sub-County has 108 VHTs who are supervised by the PHC team. The leprosy Assistant retired from service but available for consultation when there is need.

The national health policy developed operational responsibility for delivery of the minimum health package to the HSD and it is expected to provide overall day to day management of the health units and community level health activities under its jurisdiction. Its specific functions include:

1. Leadership in planning and management of health services within the HSD including supervision and quality assurance. This is quarterly followed up through meetings with the HU in charges.

2. Provision of technical, logistical and capacity development support to the lower health units and communities. This HSD is relevant in contributing to progress in service delivery and the below narrative report is evidence of the activities carried out.

3. Coordinating community health department through health centres under its jurisdiction. One of the key priorities is improved access to treatment of HIV clients to reduce the number of death associated with HIV and to control its spread in the HSD. The community health department in conjunction with the HIV clinic has been carrying outreach activities to support Apeitolim, Lotome, Lorengecora and Kangole Health unit to offer integrated HIV care services which include; HCT, EID, CD4 testing and TB/HIV co management. With the new policy on HIV care services MoH accredited HC IIIs to run HIV Clinics, Matany Hospital transferred clients to Iriiri, Apeitolim, Lorengecora, Lotome and Kangole HCs as a strategy to minimise poor adherence to treatment however the Hospital still gives assistance to these health centres in caring for HIV patients. Although the strategy was aimed at improving adherence. Lost to follow patients on ARVs has continued to rise and according to ART clinic records the cumulative number is about 2,040 with only 475 active or regular cases, and 1,250 lost to follow up. CUAMM did support a few components of HIV care in this Financial year still there has been gap both in EMTCT and Lost to follow up particularly those residing in our catchment area requires new appropriate interventions to address it.

4. Monthly support supervision of peripheral health units integrated with eye care, health education on common diseases and community resource persons meetings.

5. Through the peripheral health units and VHTs the following activities have been carried in the HSD; guinea worm eradication activities, TB case finding and contact tracing, malnutrition screening, patient referral and follow up, identification of people with disabilities, surveillance of epidemic out breaks and case finding; and follow up of chronically ill patients.

19 of 108

 Peripheral Health Units and staffing levels

Table 2.3: Personnel by qualification in Bokora HSD Peripheral Health Units as 30/06/2018

HEALTH UNIT Lab. Lab. Lab. S.N.O Nurse Nurse Nurse Health Officer Officer TOTAL Clinical Midwife Midwife Assistant ssionnals ssionnals Dispenser Certificate Certificate Assistants Assistants Registered Registered % of profe- Ophthalmic Ophthalmic

(OWNER-SHIP) Info Asstant Technicians 1 HC III standard + 1 1 1 1 2 2 1 1 3 1 1 1 0 17 100% by Government SCO

IRIIRI HC III 2 1 1 1 3 4 1 1 2 1 1 1 1 20 133% (Govt)

KANGOLE HC III 1 0 1 0 2 1 1 0 2 1 0 1 0 10 67% (Cath.Church)

LOKOPO HC III 2 0 1 0 2 2 1 0 3 1 0 0 0 12 80% (Govt)

LOPEI HC III 2 0 0 0 2 2 1 0 2 1 0 1 0 11 73% (Govt) LORENGECORA 2 0 0 1 3 2 1 0 2 1 1 0 0 13 87% HC III (Govt) LOTOME HC III 1 0 2 0 2 2 1 0 2 1 1 0 0 12 80% (Govt)

HC II standard by 0 0 1 0 1 1 0 2 0 0 0 0 5 100% Government Nawaikorot 0 0 0 0 3 2 1 0 1 1 0 0 0 8 160% HC II (Govt) Amedek HC II 0 0 0 0 2 1 0 0 0 0 0 0 0 3 60% (Govt) Morulinga HC II 0 0 1 0 3 2 0 0 4 1 1 0 0 12 240% (Govt) Apeitolim HC II 1 0 1 0 2 4 0 0 1 1 0 1 0 11 220% (Govt.) Nabwal HC II 0 0 0 0 2 1 0 0 1 0 0 0 0 4 80% (Govt.) Nakicumet HC II 0 0 0 0 2 1 0 0 1 0 0 0 0 5 100% (Govt) Namendera 0 0 0 0 2 1 0 0 1 0 0 0 0 4 80% HC II (Gov’t) Kalokengel HC II 0 0 1 0 0 0 0 0 0 0 0 0 0 1 20% (Govt)

TOTAL (current 11 1 9 2 30 25 7 1 22 9 4 4 1 126 102% staff) Qualified 1 -1 -3 -2 -4 -5 7 -1 6 -3 2 2 -1 -2 -2% Staffing Gap Total (ideal 12 0 6 0 26 20 14 0 28 6 6 6 0 124 100% staffing)

In the above staffing table for HC III's and II's, 2 support staff and 2 guards are not recorded, but they are part of the staff establishment. Only nursing, clinical staff and health assistants are listed. The total staffing levels shown by the table indicate the HSD health centres have adequate staff of 98% however it is important to note that three health centres II’s; Apeitolim, Morulinga and Nawaikorot are practically being operated as health centre III's due to their set up and the unique needs of their communities thus the real picture of the staffing levels is more lower than what is revealed in the table. The senior nursing officer at Iriiri Health Centre has been posted there in preparation for the up grading of Iriiri from Health Centre III to IV.

20 of 108 C) Activities/Achievements

The Community Health Department has made positive gains in improving access to health care services and improved quality of care for the population it serves however the overriding priority to reach all the underserved populations in hard to reach areas remains a major challenge. The department conducted regular supervision to thirteen peripheral health units of Bokora Health Sub District and offered a package of services to the community that are in line with the concept of PHC: MCH/FP/, UNEPI, TBLCP, CBR, EDMP, school health, dental care and primary eye care activities. Community surveillance on guinea worm continued in this financial year but no new case of guinea worm has been reported. Integration, community participation and multidisciplinary approach are the basis of PHC team activities. ART and EMTCT services are carried out in collaboration with the seven accredited lower health units however some clients still prefer to come back to the hospital to get their treatments because of complains of no availability of staff at the health centres on some days when they come for medicines refill. EMTCT services has also been difficult to implement in this financial year because there was no support from partners to midwives to follow lost up mothers which reduced accessibility to HIV care and adherence to treatment by clients. The counsellors in the community health department and midwives in the peripheral health units are mandated to follows up mothers on Option B+ and their babies in the catchment area. The HSD has been involved in training health workers and Village Health Team members’ in vitamin and mineral powder to help reduce micronutrient malnutrition which is chronic in the HSD. This micronutrient powder is given to children aged six months to 59 months. Score card assessment was done in all health facilities during this period to facilitate the review performance within the quality improvement framework and some health units were found to be making progress.

Activity areas include the following:

 Support supervision to peripheral health units (Govt. & Non Govt.) and supply of logistics

The PHC Supervisor and team in FY 2017/18 visited each of the thirteen units monthly and compiled a report submitted to District health office and the Chief Administrative officer Napak district with copies to relevant offices. The Support supervision was conducted with the aim of ensuring correct patient management and continuous quality assurance improvement. The activities supervised include clinical assessments and prescription habits to ensure rational drug use (EDMP), HMIS monitoring, UNEPI cold chain maintenance, supervision of Maternal and Child health related activities and generally quality of services offered at the health units. Problems identified by the unit staffs or the supervisor were discussed at the end of the working day and possible solutions (which form the basis for subsequent supervision) were suggested and agreed upon for implementation.

Table 2.4: Support supervision visits to peripheral health units in Bokora Health Sub-District (including Matany Hospital OPD)

Health Units’ 2008 2009 2010 2011 2012 2013/ 2014 2015 2016 2017 Target 2017 Supervision /09 /10 /11 /12 /13 14 /15 /16 /17 /18 /18 No. of visits to 96 96 96 100 120 117 112 118 136 126 156 Government units No. of visits to 12 12 12 11 12 12 12 12 12 12 12 Diocesan units Total visits to all 96 108 108 108 111 132 129 124 136 138 168 units Total no. of the units 9 9 9 9 11 11 11 13 13 14 14 Average visits per 12 12 12 12 12 12 12 10 10 11 12 unit

21 of 108  Provision of Health Care in Hard to Reach Areas The ongoing rapid increase of the population relocating to new settlements remains one of the major challenges facing the Health Sub District where these communities lack health care services and are in dire need of maternal and child health services that include immunization, antenatal, health unit delivery among others. In the past there has been exodus of the local population to other districts with more numbers going to urban areas including streets and Kenya towns. A significant number of the population (40%) also shifted from their original catchment areas to new settlements along the border with Nakapiripirit, Katakwi and Amuria districts and in the year 2017/18 more new settlements of Kakorinyang, Kotirwae and Nyarikidi among others have been added to the old ones, stretching the increased demand for outreaches to provide health care and other social services yet the budget for responding to these unique challenges has not changed and the department suffered a setback in accessing the support from UNICEF for hard to reach areas that changed its channel through CUAMM to the district directly. The department conducted the outreaches with this support twice only since the UNICEF funds reaching the district rarely trickles to HSD. A number of integrated services offered to these vulnerable communities include; immunization, antenatal care, eye care screening, health education and treatment plus attending to patients with different conditions. These communities have expressed their appreciation to the hospital and partners for reaching out to them.

 Maternal and Child Health

Maternal health, new born and child health are closely linked and HSD in line with Uganda Ministry of Health takes it as a priority injecting inputs for collective action in reducing preventable maternal, new born and child death. The hospital promotes good practices including 24 hour ready ambulance with an emergency midwife to transport mothers from lower level health units supporting the ambulances in those health centres that are prone to mechanical problems due to poor maintance. A Double trained registered nurse (URM/URN), supervised by a Medical Officer is responsible for the Maternal and Child health activities in the Health Sub District. The Health Sub District had 204 trained TBAs in all the Sub Counties in the previous years but since the Ministry of Health stopped TBAs from conducting deliveries the Heath Sub District down sized their number to 104. TBAs have redefined roles to mainly mobilisation of communities for antenatal services, health education and escorting or referral of mothers for antenatal and delivery services in the nearest health unit. Antenatal services are conducted in all HC IIIs daily and in the Hospital from Monday to Friday. Significant gains continue to be realised in the Health Sub District notably the skilled deliveries. Skilled deliveries in FY 2017/2018 were 4744 from 4555 in FY 2016/17 which accounts for 4% increase. This was an increase from 60% of supervised deliveries in FY 2016/2017 to 64% in FY 2017/18. However the fourth antenatal visits remain low. Maternal health services has been a combined effort of the district, hospital and some implementing partners. UNICEF through CUAMM continued to pay for the transport of some mothers in labour to the nearest health unit through a transport voucher system though it was scaled down compared to the last financial year. With this system any transporter who takes a mother to a health unit is given a voucher which is paid on a later date by CUAMM. This system is intended to minimise on the ‘second delay’ to access delivery services to mothers in labour.

 Uganda National Expanded Programme on Immunizations (UNEPI)

Bokora County has thirteen static units (corresponding to the number of health units supervised by the Primary Health Care Department) and 84 outreach posts distributed all over the county. The four hard to reach areas are also reached monthly whenever logistics are available giving a total of 124 outreaches. Each sub-county has an average 8 outreach posts run by the health unit staff and some of the Filed Health workers attached and facilitated by the Peripheral Health Units respectively.

22 of 108 Table 2.5: Immunisation coverage by antigen for the six killer diseases in Bokora Health Sub- District over the last six years

Coverage Coverage Coverage Coverage Coverage Coverage National Antigen 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 Target BCG 100% 98% 109% 143% 101% 91% 100% DPT3 100% 100% 118% 163% 126% 122% 85% MEASLES 100% 100% 100% 190% 129% 109% 95%

TT2+ P 50% 50% 57% 58% 78% 68% 50%

TT2+ NP 27% 50% 45% 47% 31% 18% 50%

Immunisation is geared at providing equitable access to existing vaccines to children and women of child bearing age. Trends in child immunization in the Health Sub District have been encouraging over the years as indicated in the above targets that have been met and even surpassed except for TT to non-pregnant women. The FY 2017/18 immunisation coverage for BCG suffered a setback below the national target of 100% where 91% children were immunised in 2017/18 compared to 101 in the previous year. The low coverage for BCG and TT for non-pregnant women is attributed to reduction in the number of outreaches conducted in this financial year. This was because the funds UNICEF provides the district to conduct this activity does not trickle to the HSD as expected thus the utilization of UNICEF funds leaves a lot to be desired. There are many children born in ‘hard to reach’ areas but unable to access BCG immunization and by the time the once in while outreach reaches them they are past their appropriate time to get it. Mothers also don’t bother any more to bring their children for it. This is one of the chronic challenges that has not been rectified. On the other hand the factors contributing to high number of immunisations among children for DPT3 and measles is attributed to the good mobilisation and vaccinations done during the outreaches. Unlike vaccination for BCG, for other vaccinations children are brought to be immunised even if they had missed their rightful schedule. The population figure of the district is also not well certain since there are different figures used. This is because the last census was conducted at the time when many people had gone outside the district but now people keep coming back to villages making projections difficult. There are also settlements that have high numbers of children of immigrants from Nakapiripirit and Amuria districts. These include; Nabwal, Nakayot and Apeitolim. Kaeselem, Komutrunyo, Kakorinyang among others. Tetanus vaccination among pregnant women has reduced by 12% and also for non-pregnant women reduced by 42%. TT to non-pregnant women is low because few outreaches in hard to reach areas, inactive school health programs, low knowledge on the benefits of TT immunization among young girls and phasing out immunization during social gatherings such Sunday.

The contribution of the Hospital and its community health department to the National development plan and sustainable development goals is commendable. This is especially in reducing infant and maternal mortality, tuberculosis identification and treatment of multi drug resistant TB. Ambulance services from Matany Hospital reach every mother in need of hospital delivery and is readily available 24 hours. Maternal and perinatal death audits are being conducted in the HSD.

The department collaborates with frontline health workers in form of Village health teams and other community resourceful persons. The establishment of Village Health Teams was done in 2010 with support from UNICEF as strategy to reach communities and households in the HSD. The HSD had 634 village health team members as per FY 2017/18, male and female per village. They continue to implement integrated management of fever, diarrhoea and pneumonia for under five children (ICCM) with good results. This is indicated by the reduced load of OPD attendance of children in all health facilities. However VHT meetings

23 of 108 have been irregular since IRC stopped being the lead partner three years ago. This may reverse the gains being made. The community health department is making little progress in reducing fertility, malnutrition, and the burden of HIV/AIDs is not effectively controlled and alcohol abuse has also reached alarming levels causing multiple problems among the population.

 PELF (Programme of Eradication of Lymphatic Filariasis)

Lymphatic Filariasis, one of the neglected tropical diseases, is a disease caused by a filarial worm called Wuchereria Bancrofti. These worms are widely distributed in Karamoja (prevalence: 2-9%, survey done in 2002). Only two species of mosquitoes, known as Anopheles Gambia and Funestura, can spread the disease to human beings. The inoculated worms develop in the lymphatic vessels of a human being and once the above mentioned mosquitoes pick them from the blood of the affected person, the worms become adults and ready to infect others human beings. A mass distribution campaign of ivermectin/ albendazole to all people older than 5 years was carried out in December 2007. In October 2014 a mass drug distribution, it was the 5th round so far, expecting to have a significant impact on the drop of all the neglected tropical diseases and intestinal worm infestation in communities of Napak. The disease burden is at 3.4% in the district. The district did conduct this mass drug distribution in November 2016 and the prevalence of lymphatic filariasis and trachoma has significantly gone down.

 PRIMARY EYE CARE

The Community Health Department has a Primary Ophthalmic Assistant who provides eye care preventive and treatment services which include; health education on primary prevention of eye problems, treatment and simple surgery of simple eye problems on daily basis. Complicated eye cases are referred or booked for the annual eye surgery camp. Annual eye surgical camps continues to be conducted in the HSD the FY 2017/2018. Three surgical camps were conducted. Two camps were conducted by St. Benedictine Eye Hospital Tororo under the CASH program for which cataract surgery was performed in Lorengechora and Iriiri. One camp was for trachomatous trichiasis conducted by Sight savers in Lokopo, Lopeei and Ngoleriet sub counties. A total of 317 Patients were operated. Cataract is the main indication for surgery.

Table 2.7: Primary Eye Care

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

No. of uncomplicated cases treated 692 1,039 1,045 1,470 1,470 1,715

No. of cases operated 394 333 455 686 236 239

No. of cases referred 8 6 8 6 2 44

The community health department of the hospital is the backbone of the eye care services in the entire district although there are two ophthalmic clinical officers trained in the district their impact is only felt during eye camps not in the daily OPD output. Eye care services have improved over the years with the number of patients seen increasing. However village outreaches conducted by the ophthalmic assistant using the motorcycle reduced because of breakdown of his motor cycle which has been repaired. Trachoma and TT cases have significantly reduced due to the campaigns held in the last three years.

24 of 108 Table 2.8: PHC Department: Ophthalmic cases seen during Financial Year 2017/2018

Ophthalmic Assistant Workload during FY 2017/2018 including static clinic and outreaches Eye disease No. Eye Surgery No. Normal eyes 33 LID Rotation 00 Allergic eyes 1,060 CAT 114 Acute red eyes 91 TRAB 0 Cataract 383 Enucleation 0 Glaucoma 12 Foreign body removal 0 Corneal scars 39 Retina 0 Active trachoma 14 Other intraocular 0 Non active trachoma 4 Other extraocular 0 Ocular trauma 54 Eviscerations 0 Refractive errors 48 Carcinoma/pterygum 0 Other diseases 146 EZIA (Aniridia) 0 Others 0 Total eye surgery 239 Total eye diseases 601 Outreaches 112

 SURVEILLANCE of Epidemic Prone Diseases

Surveillance reports have been collected on weekly basis from all the Peripheral Health Units of Bokora Health Sub-District throughout the Financial Year 2017/18.

The table below shows a summary of cases reported since 2014/15 to 2017/18

Table 2.9: Notifiable Diseases during FY 2014/2015 to 2017/2018

FY 2015/2016 2016/2017 2017/2018 Cases Cases Cases Disease Deaths Deaths Deaths reported reported reported Cholera 0 0 0 0 0 0 Bacillary Dysentery 1,108 0 728 0 708 0 Measles 3 (suspects) 013(suspects) 0 153(suspects) 0 AFP/Polio 0 0 0 0 0 0 Bacterial meningitis 15 0 29 0 17 1 Haematological Meningitis 1 0 28 0 2 0 Malaria 84,265 67 59,144 62 49,117 21 Neonatal tetanus 1 1 1 1 0 0 Plague 0 0 0 0 0 0 Typhoid 278 3 84 2 73 0 Yellow fever( suspects) 0 0 0 0 0 0 VHF 0 0 0 0 0 0 Guinea Worm 0 0 0 0 0 0 Animal bites/ Susp. rabies 354 1 60 1 98 0 Chicken pox 287 0 165 0 0 0 SARI 0 0 0 0 0 0 Maternal Death 0 4 0 4 2 2 Perinatal Death 0 20 0 20 30 30 Hepatitis E (HEV) 20 (suspects) 0 20 (suspects) 00 (suspects) 0

25 of 108 Malaria is the leading notifiable disease with 49,117 cases seen in HSD out patients departments and 3,331 cases were admissions out which 21 deaths were registered in FY 2017/2018 with case fatality of 0.4%. Two maternal deaths occurred in the Hospital and they were reported to the ministry and maternal death audits done. Poor personal and environmental hygiene are primarily responsible for high numbers of bacillary dysentery since majority of people still practice open defecation The introduction of Hepatitis B vaccination was started in April 2016 with social marketing at the market premises by the hospital team and there has been good uptake of vaccination as many people turned up for testing and immunization. The HSD tested 2,482 people for Hepatitis B out which 528 were found to be positive that’s 21% compared to 16.4% in the last financial year. Syphilis also continues to be a burden to the population where 3,484 were tested for it and 397 turned positive with 11%.

HEALTH EDUCATION

Health promotion and education supports all other elements in the minimum health care package was conducted at individual, family, community and Health Units level. The Health Educator, Hospital staffs, students, and Field Health Workers continue to carry out the activity using various methods and tools to facilitate learning through voluntary adaptation of knowledge, attitude, behaviour, and practices for disease prevention, control and health promotion. It is quite evident that people’s attitudes are increasingly changing towards western medicine practices. It is still a common finding that some people have been to the traditional healer before coming to the Hospital but on a general note the health seeking behaviour of the community is gradually improving.

Problems/Constraints faced

 New settlements and nomadic lifestyle.  Traditional and cultural beliefs, conservative tendencies.  Cost of funding outreaches is high with minimal support from government  Poor road network to some areas especially during the rainy season  Poor coordination of activities with other implementing partners in the District  Limited funds to carry all the health education services expected  Creation of new health centre 11s which are not recognised by central government  Lack of medicines and medical supplies to Namendera, Nakicumet and Kalokengel health centres from NMS  Old car used by HSD for outreaches.  Lack of enough accommodation for staff in all the health centres.  Breakdown of EPI fridges in some facilities like Ngoleriet HC. Amedek health centre has no EPI fridge.  Poor laboratory services in all health centre IIIs mainly due to lack of personnel, lack of supplies or inadequate skills.  Inadequate staffing in health centres.  Staff houses under construction by Italian Cooperation have stalled at wall plate level.  Poor lighting in some facilities like Lotome HC.

26 of 108 Plan for next Financial Year 2018/19

 Improvement of infrastructure in all health centres.  Fencing of Amedek and Nakicumet health centres.  Procurement of a new car for the HSD for outreaches  An additional Ophthalmic Assistant to be trained or recruited in future when possible to serve in both in general OPD and attend to eye care attendees in eye clinic during some days when the assistant ophthalmic assistant is out in the field.  Advocate to have Nakicumet, Namendera and Kalokengel health centres get recognised by government and start receiving drugs and medical supplies from NMS.  Advocate incorporation of HSD work plan to the district plan that is supported by UNICEF to be able to offer sustainable services to the population in the new settlements and to carry out HIV/AIDS activities especially family support groups and EPI outreaches.  Strengthen data/ HMIS management through the newly qualified health information assistant.  HSD to continue with its support supervision, training and mentorship of staff in lower level health units.

27 of 108 CHAPTER THREE

GOVERNANCE AND MANAGEMENT

The Hospital operates under the direction of the Board of Governors (BoG), which takes its mandate from the Board of Trustees of Moroto Catholic Diocese through its Chairman, the Bishop. The Hospital constitution indicates that BoG meetings be held four times during a financial year. The flow chart below shows the Management Structure coordinating with the Hospital Management Team.

Board of Trustees of Moroto Diocese

Ministry of Board of Governors Uganda Catholic Health St. Kizito Hospital Medical Bureau Matany (UCMB)

District Health Diocesan Health Authorities Coordinator (DHC) Hospital Management Team: Headed by Chief Executive Officer, and consisting of the heads of the main departments

Medical Nursing Administrative Public Health Health Training Director Director Director Director Institution Director

Medical and Nursing Accounts / Prevention Tutors, paramedical departments; Administration and health Clinical departments Nurses and department; promotion in Instructors, / staff; nursing Maintenance own catch- Support Staff Diagnostic support staff. infrastructure, ment area; and students departments Cleaning and Equipment HSD services Pharmacy Domestic and Grounds; and activities Department Transport

Legend: - Hierarchical Authority and communication line = - Advisory Authority and communication line =

St. Kizito Hospital Matany Constitution - 11

As seen above the Hospital is owned by Moroto Catholic Diocese with its legal entity the Board of Trustees.

The religious congregations working in the Hospital have signed Agreements with the Ordinary defining the number of personnel of the congregations to the Hospital.

28 of 108 Governance:

Moroto Diocese has a Diocesan Health Commission (DHC) that oversees policy implementation and statutory undertakings for the Diocesan Health Institutions. The Hospital is represented in the DHC by the Medical Director and the Principal Tutor.

The Board of Governors:

St. Kizito Hospital Matany Board of Governors is the supreme governing body of the Hospital and Nursing and Midwifery Training School. As such it is custodian of – and shall ensure compliance to the Constitution of the Hospital. The list of BoG members is in Annex 2.

During FY 2017/18 there were three BoG meetings and the Induction of Members of Board of Governors.

Table 3.1 BoG meetings

No of Dates of Board Reports presented / Key issues handled / decision Members meetings taken present Faithfulness to the Mission Report & Performance 28/09/2017 1 13 Report 2 Annual Analytical report 2016/17 3 Presentation of the budget for FY 2017/18 4 New Edition of the Hospital Charter NMTS brief Report 5 PHC - brief report 6 Updates from Management 08/12/2017 1 Feedback on Cervical and Breast Cancer campaign 9 2 Audit Report FY 2016/17 3 Budget FY 2017/18 4 NMTS – brief report 5 PHC - brief report 6 Communication from Management 25/04/2018 Board Induction and Induction of the 20 HTI Statutory Committee Results from Patient Satisfaction and Drug Prescription 05/07/2018 1 11 Surveys 2 Hospital Budget FY 2018/19 3 NMTS – brief report 4 PHC - brief report Communication from Management 5  CUAMM - Support towards NMTS

During the BoG meeting of 28th September 2017 a report on the Faithfulness to the Mission was given. In summary it was noted, that 1. Accessibility has increased, as five out of five parameters have improved, namely OPD attendance, admissions, deliveries, Immunisations and Antenatal visits. 2. Concerning equitable services it was noted that user fees/ SUO, which are still very low as compared to UCMB-network, has increased. The Hospital Administration has to continue to look for funds and donations to keep the highly subsidised fees as low as possible. 3. Efficiency decreased, because Recurrent Cost/SUO increased and staff productivity decreased. This was due to the fact that more qualified staff were employed. However it is hoped that a higher professional quality health care was given. 4. The indicator of Quality services remained high, as maternal deaths and fresh still births reduced, the Caesarean Section Infection rate remained by 0%, the percentage of qualified staff increased and the recovery rate was at 97.1%.

29 of 108 The Board was informed of some specific areas of the Annual Analytical Report. It final printed comprehensive version will be available at the end of December 2017. Concerning the Hospital Budget which could not be prepared in time due to the absence of the Administrator for a long time, the Board authorised management to use funds outside the budget. A small committee consisting of the Parish Priest, the CAO, the DHO and the Chairperson were to verify the budget prepared by the Administrator on Friday, 13th October 2017 starting at 9:30 a.m. in the Board room. All members received a soft copy of the Hospital Charter with the foreseen changes by e- Mail to familiarise themselves with this document. The MS presented the changes of the Hospital Charter and members were requested to comment immediately after each change was presented. After all the changes were discussed, one member proposed that the new charter be approved which was seconded. In her report, the Principal Tutor of the HTI presented the Faithfulness to the mission report to the Board. The main areas in the report were accessibility, equity, efficiency and quality. Then the brief PHC report followed. During the updates from management members were informed that: 1. The Water project is in progress. Pipes were laid and two new tanks erected. What is missing are the connectors between the pipes which were ordered from abroad because of better quality. They should arrive in October. 2. The new x-Ray machine (PROTEC) financed through Rotary International was officially handed over to the Hospital in August 2017 by Rotary Officials from Port Bell. Prior to it, it was successfully installed and put to use. 3. A communication from Dr. Lochoro, CUAMM was read. The new project supporting Matany is part of a 5 year project beginning 1st May - "Mothers and Children first". It will be MNH and Nutrition support and TB. The direct support to the Hospital will be the salary for the MS, salary for the Surgeon, compensation for caesarean sections that will be given in drug equivalent. Then there will be support for nutrition supplies and activities.

The first agenda item shared during the BoG meeting of 8th December 2017 was the report on Cervical and Breast Cancer Campaign. The campaign begun on 23rd October and ended on 3rd November 2017. It was a partnership between the Hospital, AFRON Oncology for Africa and UWOCASO (Uganda women cancer support Organisation). It started with sensitization of community leaders and female VHTS in five sub counties of Nabwal, Lorengechora, Matany, Lokopo and Lopeei. Screening was carried out in Nabwal, Lorengechora and Matany Hospital. 515 community leaders were sensitized with 703 women screened for cervical and breast cancer. 32 women were found to have early cancer and were treated using LEEP. 8 staff in LLHUs were trained. The Chairman was concerned about the sustainability of the service. The MS informed that staff in lower facilities have been trained and that screening doesn’t require many logistics. Any trained midwife can do it. Staff in LLHUs were left with the acetic acid to use. Members were informed that the service is always available in the hospital not only during camps. A woman can walk in the hospital and get screened.. Next followed the presentation of the audit report of FY 2016/17 by the Hospital internal auditor. Some few recommendations of the auditors were to keep job descriptions in the personnel files of the employees, to have regular written reports presented by the internal auditor and have the Asset Register updated. In a next agenda item the Hospital budget for FY 2017/18 was presented. The effects of inflation were considered. The NMTS still needs more renovation. However apart from regular maintenance, major renovation can only be done, once the funds pledged from the Office of the Prime Minister have arrived. The chairman noted that the budget showed a small positive balance. The budget was approved.

30 of 108 The Principal Tutor The Principal tutor presented the NMTS report. One diploma nurse and one diploma midwife have joined the teaching staff. Two new students of the November intake 2017 were found to have serious medical conditions during their school entry medical examinations and could therefore not take up the training. Finally a report on recent PHC activities was given: The PHC supervisor presented the PHC brief report. She reported of the new initiatives to improve maternal and new-born health (MNH) in Napak District which were discussed in a district midwives’ meeting in November 2017. The program is supported by CUAMM. Matany Hospital has been selected as a model Hospital for implementation of this program. Some midwives in LLHUs are rude and violent to mothers and for this they must stop. The HSD team must supervise midwives, advise them to improve on their attitudes and stop such acts or else be disciplined. The Management requested the Board to appoint Mr. Lokol Thomas Aquinas as Deputy Administrator. Mr Lokol is a holder of a Bachelor’s degree in information technology and a Master’s degree in Health service management. The board noted the importance of having a deputy administrator and consequently Mr. Lokol was approved as a deputy administrator of the Hospital. Other Communication from Members and Management:  Hospital accreditation for 2018 to UCMB network. Matany Hospital emerged as the best performing hospital in UCMB network for FY 2016/17 with a score of 97%. The chairman thanked the Hospital for the excellent performance.  Inauguration of the new staff house with 6 housing units. On 1st November 2017 the Hospital inaugurated a new staff house with 6 housing units. The house was built with support from Milano-Matany support group which was represented by Ms. Federica and Mr. Pietro. It was blessed by Matany Parish priest.  Update of MDR-TB The MS presented the Hospital MDR-TB activities. The Hospital has an MDR-TB management program being supported by CUAMM. The program started in February 2017 and 38 patients have so far been enrolled in the clinic. 4 completed treatment. Patients come from all districts of Karamoja and Katakwi. Nakapiripirit has the highest number of patients -17. It was noted that Karamoja has poor TB indicators with Nakapiripirit performing worst. RHITES-E is supporting Kotido and Moroto Districts. CUAMM is to increase support for TB activities in the new FAI project next year. It was reported that there are several TB patients admitted on TB ward but have been abandoned by relatives, the PHC team was tasked to trace for the relatives of these patients.  Moroto Diocesan health facilities performed well in FY 2016/17 and Moroto Diocese emerged the 2nd best performing Diocese within the UCMB network.

The third BoG meeting on the 25th April 2018, was arranged to be a Board Induction as well as an induction of the HTI Statutory Committee. Dr. Ronald Kasyaba the Deputy Executive Secretary of UCMB and Sr. Catherine Nakiboneka, the UCMB-Coordinator - Health Training Institutions & Training were orienting the Board and HTI Statutory Committee on their roles and key elements of governing. Members were made aware, that Governance is “ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system-design, and accountability (WHO,2007). It is a means by which Board directs & controls the Hospital’s performance and achievement of Mission. The seven governance roles were highlighted. They are: 1. Strategic Planning, Setting the Strategic Direction

31 of 108 2. Oversight of Quality & Performance measurement & monitoring 3. Financial Oversight 4. CEO selection (HMT) and Performance Evaluation and Succession Planning 5. Risk Identification and Oversight 6. Communication and Accountability 7. Representation (Community, External World) Further it was emphasised that the Governance Roles must protect the Catholic Identity of health Service delivery. There are Seven Constitutive Elements: 1. Promote and Defend Human Dignity & Respect for Human Life (even the unborn) 2. Attend to the Whole Person,  Physical, Mental/Emotional, Spiritual, & Socio-economic 3. Care for the Poor and Vulnerable Persons 4. Promote the Common Good 5. Act on Behalf of Justice (even for the unborn) 6. Steward Resources 7. Act in Communion with the Church The HTI Statutory Committee  Provides oversight to the Nurses/Midwifery Training School o May also perform the roles of Hospital HR Development Committee Members on the HTI Committee may also be members of the BoG Disciplinary Committee—i.e. for disciplinary issues of both Staff & Students o Consideration of scale, efficiency and effectiveness on committee memberships  The Committee is directly accountable & reports to the Board o Express delegation to implement decisions provided by BoG under certain circumstances Board and HTI Statutory Committee members appreciated the induction as they feel now more confident to exercise their role.

In his opening remarks of the BoG meeting of the 7th June 2017, the chairman noted that quite considerable number of Board members are not turning up to the meeting. There is need to evoke the constitution if members are absent for several times without apology. We have to find out why members are losing interest. Everyone is requested to find out the reasons which we should share during next BoG meeting. The Bishop had trust in the appointed members in governing the Hospital. It would be painful to call off the meeting only because the quorum is not represented. Members should own the Hospital and be interested in the development of the Hospital. The first agenda point the MS presented the results of the Patient Satisfaction and Drug Prescription Surveys. Also this year the overall satisfaction about the care given by our staff to the patients was 92.1%. There was improvement in the clinical effectiveness of treatment given, kindness of staff, patient involvement in care, waiting time and cleanliness of the Hospital. However privacy during provision of care needs to be improved. The drug prescription quality score was 95.5%. The antibiotic rate was higher than the WHO recommendation. The Hospital Budget for FY 2018/19 was then discussed after it was it was presented by the Administrator in its usual format. As comparison the budget of the previous year and the projected expenditure of the just ended FY 2017/18 was presented with the budget figures for 2018/19. - However there is also need to come up with a workplan which is to support the budget. The DHO was requested to give us technical support. In response the DHO informed the house that from this Financial Year 2018/19 onwards a software is online and linked to the MoF. Quarterly reports are to be entered into this software. The DHO is planning a technical retreat for this new reporting system and come up with a workplan linked to the budget. The DHO was requested to inform the Hospital

32 of 108 Administration when these new "tools" are introduced and trainings are conducted so as to involve the Hospital. For the to be designed annual work plan, the Strategic Plan 2016-2021 of the Hospital will be a valuable guiding tool. After further discussions the budget was then approved. The Principal Tutor informed in her report about the current school population, teaching and administrative staff. Among the updates were following points:  One part time Midwifery Tutor, the Principal of DAF School of Nursing and Midwifery, was identified and has offered to teach the Midwifery students (two weekends/month).  The MoES has introduced Semester System Assessment of student Nurses and Midwives; the Semester examinations are to be conducted in the last two weeks of June and first two weeks of December respectively. This is followed by three weeks semester holidays.  The courses for Nursing and Midwifery students Intakes have been scheduled to start in January and July in order to fit in the semester system assessment.  The new curricula emphasizes on five weeks Recess Semester placement in the Clinical setting of all nursing and midwifery students.  Accreditation of our HTI by the Health Commission of UEC for the period FY 2016/2017. Matany HTI was one of the best two in the UCMB Network for the period indicated. Forthcoming and on-going activities:  Intake of November 2017 are for three weeks holidays while May 2016 Intake are for Recess Term placement in our Hospital.  The new students Intake July 2018 will report for their training on 20th July 2018. CN are 22 and CM 23.  Two weeks field attachment of Intake 2016 to Kangole HC III will be after their holidays.  Family Planning activities for Intake 2016 in Moroto Regional Referral Hospital will also take place soon  End of PTS Examinations for CN and CM 2018 July Intake will be in October 2018  End of Semester examination will be in December 2018 for all the students in our HTI  The review of the School Rules and Regulations is due as well as the  Review of Admission Procedure and Selection Criteria for candidates in the training School. The PHC - Public Health Nurse presented the Community Health Report. The DHO thanked the PHC Department especially for the support supervision to the Health Units. The Supervision Reports are much appreciated with positives, negatives and recommendations. This has greatly improved the performance in the HU's. Challenges are of administrative nature which at times are carried on due to financial constraints, etc. A reduction of partner supports is greatly felt. The biggest challenge of recent were the inaccessible hard to reach areas due to flooded roads. Irish Aid will support the District for HIV activities of which some could be directly financed to the Hospital. Other Communication from Management / CUAMM:  Support towards NMTS - CUAMM presented a project in support to Matany HTI to Elma a foundation in the US. Following areas will be supported: Sponsorship of 20 Karimojong students, some staff salaries, scholastic materials, support students’ community experience etc.  As there is currently no Chairperson for the HTI Statutory Committee, the BoG Chairman suggested that Fr. Denis, Parish Priest of Matany could accept this task, which he willingly did.

33 of 108 The Hospital has a Disciplinary and Welfare Committee with the main function of ensuring proper conduct by the staff. The disciplinary committee meets whenever a disciplinary evaluation is urgently needed.

The role of the Hospital Communication Officer is performed by the Administrator. An Ad Hoc job description and a draft of communication policy within and outside the Hospital are in place and need to be finally discussed by the BoG.

Since July 2015 a Human Resource Officer was employed by the Hospital. Job descriptions and employment manual are available for all cadres and clearly spelt out in their appointments. - General Staff assemblies are regularly held.

The Hospital recognised the need for the internal system management /process Auditor. This position is covered by an IT Officer. He was sent for studies for a Master of Science in Health Service Management and returned to the Hospital in August 2016. In its December 2017 meeting the BoG further appointed the IT Officer as Deputy Hospital Administrator. Amidst many other tasks, he will keep an eye on the following together with the Accounts personnel:

 The Internal stock management processes  The internal control procedures  Follow up on record keeping of all supporting documents for all transactions in the year

Management

The Hospital is managed by the Hospital Management Team (HMT) with its executive body, (the Daily or Executive Board), formed jointly by the Chief Executive Officer (CEO), the Medical Superintendent or Medical Director (MD) and the Principal Nursing Officer or Nursing Director (ND). This executive body meets daily (in the morning) with the main task of discussing issues arising during the day to day running of the Institution. Issues concerning finance, personnel, clinical care and project implementation are the commonest topics discussed.

The Chief Executive Officer has direct access to the Bishop in the event of need and ensures the function of liaison with the Uganda Catholic Medical Bureau, the Diocesan, District and National Health Authorities.

 The Hospital Management Team (HMT) is composed of the executive board together with the PHC Director and HTI Director. The HMT meets regularly and the chairperson is the Medical Director. See the composition of this committee in Annex 2.

 The HTI Statutory Standing Committee is required by the Health Commission of Uganda Episcopal Conference through UCMB. This Committee is specifically responsible for providing oversight on the Health Training Institution and reports to the Board of Governors. The composition of this committee is in Annex 2.

In table 3.2 is a summary on the compliance with statutory commitments (with UCMB, Government and Ministry of Health, etc,). Management is following all these commitments seriously.

34 of 108 Table 3.2 Statutory Requirements

Did you No REQUIREMENT achieve it? Comment Yes, Partly, No Government / MoH Requirements Monthly contributions are regularly 1 PAYE Yes submitted Monthly contributions are regularly 2 NSSF Yes submitted 3 Local service tax Yes Payment is done annually 4 Annual operational licence Yes Obtained with the help of UCMB Staff are continuously reminded to 5 Practicing licence for staff Yes register with professional bodies Timely compiled, scrutinised and 7 Monthly HMIS Yes submitted to various stakeholders UCMB statutory requirement 1 Analytical Report end of FY 2017/18 Yes This is currently in progress 2 External Audit end of FY 2017/18 Yes Was done in the 42nd week 2017 Charter was updated during BoG 3 Yes Valid meeting of 28th September 2017

Did you No REQUIREMENT achieve it? Comment Yes, Partly, No UCMB statutory requirement 4 Contribution to UCMB for the year 2018 Yes Paid before March 2018

HMIS 107 PLUS financial report / th 5 Yes Submitted on 27 July 2018 quality indicators ending FY 2016/17

Report Status of staffing as of end of th 6 Yes Submitted on 27 July 2018 FY 2016/17 Manual of Employment was updated 7 Yes valid during the BoG meeting of 7th June 2017 8 Manual of Financial Management Yes still valid Report on Undertakings and Actions of Timely submitted before the 31st 9 Yes the year August 2018

Accreditation status with UCMB

Matany Hospital fully accomplished the 10 statutory requirements and hospital undertakings set by the Uganda Catholic Medical Bureau and was awarded a certificate of accreditation for FY 2018/19 with 95.8% score attained and valid until 31st December 2019. With this result Matany Hospital emerged to be the first together with Angal and Nsambya Hospital among all the 32 Hospitals under UCMB. The accreditation certificate was issued during the Hospital Managers Technical Workshop II organised by UCMB in October 2017.

Hospital Guidelines and Manuals

The Hospital Charter and the Employment Manual, were both revised and approved. The Financial and Materials Management Manual is in place and needs revision.

The Hospital Strategic Plan covering the period of July 2016 to June 2021 was discussed and approved during the BoG meeting of 15th September 2016. It is a guiding tool for the operation and management of Matany Hospital. Its Theme is: “Provide comprehensive sustainable health services that ensure healthy lives, uphold client satisfaction and respect human dignity”.

Copies of these documents are in the Hospital Library available to whoever wants to consult them. A copy of the Employment Manual is given to all the employees.

35 of 108 Up to now the Hospital has no approved Information, Communication, and Data Management Guidelines which will have to be formulated and approved and then implemented.

Advocacy, Lobby and Negotiation

The Hospital Strategic Plan for 2016-2021 was approved in September 2016. It will be used as an advocacy tool for the Hospital. The Hospital has continuously advocated for better health service delivery to its catchment area through the DHMT where the Medical Director is a member, UCMB, MoH, donors, and other partners. In October 2017 the Hospital conducted a sensitization programme of community leaders (politicians, elders, VHTS and health workers) in five sub counties of Matany, Nabwal, Lorengechora, Lokopo and Lopeei in Napak District on Hospital updates. The objectives of the sensitisation were: to get a feedback from the community about the services provided by the Hospital Attended Napak District council meetings where issues pertaining health are also discussed. Regular staff meetings help to update staff on achievements, challenges and future plans of the Hospital. They actively participate in these meetings.

36 of 108 CHAPTER FOUR

HOSPITAL HUMAN RESOURCES

Introduction

During FY 2017/18 an average of 7 Doctors was present in the station at all times. Napak District has seconded seven staff to the Hospital, three working in the Hospital and four in the Public Health Department. They are: The Orthopaedic Officer, a Senior Clinical Officer, the In Charge of the Laboratory and at the PHC Department one Health Inspector for Bokora HSD, one BA-Midwife, District health educator and a Health Information Assistant. The Health Training Institution has presently three qualified Tutors: The Principal Tutor, the Deputy Principal Tutor (DPT) and a Nurse Tutor.

STAFFING

The total number of employees as of 30th June 2018 was 249. Matany Hospital continues to be one of the main employers in Karamoja Region. Graph 4.1 shows the distribution between Karimojong and Non Karamojong Personnel.

Matany Hospital Personnel since FY 2012/13 200 172 170 162 149 155 160

120

78 77 80 71 66 59 40

0 2014 2015 2016 2017 2018 Total: 248 208 221 233 249

Non-Karimojong Karimojong

Graphic 4.1: Levels of Employment at Matany Hospital since 2012/13

The output from the NMTS significantly provides the main source of qualified nursing and midwifery staff to Matany Hospital. The Technical Department relies on the supervision of one expatriate staff. The number of young Karimojong working, and willing to continue working in the Hospital longer has increased. This can be attributed to the availability of opportunities for further studies that the Hospital offers, nationwide unemployment, family attachments, and the desire to invest home while working in the Hospital. As the academic standard of schools in Karamoja continues improving, the statistics of young vibrant Karimojong candidates seeking to join Health professional courses has recently doubled. This has forced the NMTS to increase on the pass mark for selection of potential candidates. However, the high cost of education coupled with socioeconomic issues still remains a stumbling block .

37 of 108 Present situation (June 2018)

The expatriate staffs include; the Administrator (CEO), one Senior Medical Officer as a volunteer, one Nurse Tutor, a Diploma Nurse in charge of Pharmacy, the Technical Department Supervisor.

Trends

There has been a progressive increase in the availability of qualified health workers in the Hospital over the last years. The Hospital Management Team made it a priority to improve the staffing norms in various departments in the Hospital. This has been partially achieved of recent; as the number of staff intending to stay and continuing to work in the hospital after expiry of their contracts has increased. Yet the number of external applicants is high, and the constant supply from the Training School (NMTS). Therefore, the percentage of qualified staff in the Hospital has continued to increase.

%age of qualified Staff 70.0%

61% 60.0% 58.8% 57.7% 57% 51.6% 50.0%

40.0% 2013/14 2014/15 2015/16 2016/17 2017/18

Graphic 4.2: Percentage Trend of Qualified Staff since 2013/14

During 2017/18 there was an increase in the absolute numbers of qualified staff, compared to 2016/2017 as indicated in the graph above. Some staffs were given opportunity for career development guided by the perceived institutional needs.

Table 4.1: Total No of staff at Matany Hospital compared to FY 2013/14 – FY 2017/18

end end end end end June June June June June 2014 2015 2016 2017 2018 MEDICAL OFFICERS 7 7 7(1) 7(1) 7(2) ALLIED MEDICAL PROFESSIONS 14(7) 14(9) 16(10) 14(08) 18(9) NURSING STAFF 77(36) 70(43) 69(42) 79(47) 86(49) ADMINISTRATIVE STAFF 12(6) 14(7) 15(11) 14(11) 15(11) PHC STAFF 36(36) 3(3) 6(6) 5(5) 6(6) TECHNICAL STAFF 39(29) 36(30) 38(30) 38(30) 41(34) SUPPORT STAFF 46(43) 47(44) 53(42) 53(42) 54(45) SCHOOL STAFF 13(9) 13(9) 13(9) 16(11) 18(12) KHRDCH STAFF 4(4) 4(4) 4(4) 4(4) 4(4) TOTAL 248 208 221 233 249 ( .) = Karimojong Personnel 170 149 155 162 172 Non Karimojong Personnel 78 59 66 71 77

38 of 108 Turnover of Staff

In the FY 2017/2018, the Staff turnover rate has increased to 16.06. Out of the 26 staff who left, 22 were trained staff. Eight left the Hospital due to professional development, five completed their contract, four went to Local Government, two joined NGOs, one started business, one died, and one left without notice. In times when Local Governments recruited health professionals the turnover rate was going up. This happened in the years 2014/15 and 2015/16.

Table 4.2 Staff turnover

Staff FY FY FY FY FY Cadres Establishment 2013/14 2014/15 2015/16 2016/17 2017/18 Total staff 286 254 208 221 233 249 Enrolled cadres 139 128 120 126 137 152 (all combined) Enrolled staff lost 25 32 36 18 26 Turnover rate 19.76% 25.30% 28.57% 13.14% 16.06%

Turnover rate for each year is calculated as in the following example for enrolled cadres in 2013/14:

Total enrolled staffs lost (1st July 2013 to June 30th 2014)

(Total enrolled cadres available at June 30th 2013 + Total no. of enrolled cadres available at June 30th 2014) / 2

Graph 4.3 Staff turnover

Turnover Rate of trained staff in the last 5 Financial Years 50.0%

40.0% 25.3% 28.6% 30.0% 19.8% 20.0% 16.1% 13.1% 10.0%

0.0% FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18

MANAGEMENT

Human Resources’ Management is one of the most challenging tasks within an Institution operating in this region where leisure activities and social programmes are inexistent combined with poor road access and irregular transport services. Staffs have to content themselves with the simple commodities available in the Trading Centre and sometimes at high price. However, with the current upgrade of the road network in Karamoja, a satellite town like Moroto is developing and so is Matany sub-county (Napak District) which has been granted the status of a town council effective next financial year, we are hopeful that the social programmes will improve rapidly and so will the business.

The Human Resource Office has continued to grow with many Human Resource functions since its inception on 1st July 2015. Because of the complexity of its functions, the Hospital

39 of 108 Management Team has elevated the former HMIS Officer who has done a Human Resource Management BA-Course as a Deputy Human Resource Officer. The Hospital has continued experiencing growth and development in its professional cadre, currently the Deputy Administrator is fully active since the HMTs decision in consultation with the BoG was reached to have its Office operational. Nurses, Doctors, Allied Medical professionals, and other qualified cadres, work 45 hours per week while some support Staff work only 30 hours per week as stipulated by the Employment Manual (revised in June 2017). This Manual provides the guidelines utilized in Human Resource Management in the Hospital and is made available to every employee at the time of induction.

During FY 2017/18 there was an increase of the number of qualified staff and, according to perceived Institutional needs, some were given opportunities for career development. As mentioned before, the Hospital administration strives to pay competitive salaries to the employees in order to compete favourably for the job market. Therefore and also because of rising costs, there was a salary increase during FY 2017/18 of about 9%. All employees are covered by NSSF (National Social Security Fund) and are paid on a salary basis. The salary is composed of a basic salary to which some incentives (responsibility allowance etc.) are added. Recruitment of staff is from the NMTS, internal adverts and headhunt. All new staff have interviews and are inducted into the Hospital. They are given the employment manuals, job descriptions and contracts. Staff performance appraisals are done regularly with promotions effected where possible depending on the positions available. All statutory salary deductions are made. Staff movements are also regularly reported to UCMB as an undertaking.

HUMAN RESOURCE DEVELOPMENT AND CAREER

The HMT has put over the years a considerable effort in designing a career development scheme and different staff were benefiting from it, particularly Karimojong candidates. However it was observed that, in most of the cases, the sponsorship of natives was not a guarantee for retention since many prefer to work far from their relatives. Fortunately this trend has changed in the last two years with a good number of staff renewing their contracts and applying for further training through this scheme. As the resources of the Hospital become scarce also the effort to support the career development of our staff becomes a challenge. Intrahealth-Uganda supported the Hospital with sponsorship of some staff for further training. These completed their studies in November 2017. They have all been bonded and are currently working in the Hospital. The Hospital has sustained an effort for the general wellbeing of the staff in terms of a relatively attractive remuneration package and recreational programs; senior hospital staffs live in fully furnished houses with running water, intercom and electricity. All these are provided as fringe benefits excluded in salaries of senior staff. The above provisions with availability of mobile telephone network have significantly softened the typically rural surroundings. Decent housing for nurses and other staff is provided, with installation of solar lighting into each apartment. An effort to increase the number of experienced / senior staff is being looked into seriously; the justification for this is due to the fact that the experienced staff are more productive and efficient. It is from such personnel that other scarce cadres, e.g. Tutors, clinical instructors, counsellors, etc. are identified and developed.

To improve on knowledge and skills, CME’s and CNE’s are regularly carried out. These help to update the staff on the new developments in patient medical and nursing care. Topics are assigned to different Wards and doctors together with other cadres discuss the topic at their level of expertise. Visiting Doctors/Specialists occasionally offer CME’s and they broaden the type of topics and issues addressed. Topics discussed during this year include:

40 of 108 - Preparation of ORS - Care of bedridden patients - Basic imaging techniques - Dehydration in Children - Reporting and managing Hospital medical records - Management of Marburg - TB updates and quality improvement - Risk assessment of patients - Diabetes in Children - Early infant diagnosis - Management of hypoxemia - Management of Cholera - Dignity and the essence of medicine - Pain management - Patient satisfaction and drug prescription surveys - Principles of ECG - Updates on comprehensive management of MDR-TB and STR regime - Psycho social support for Children and adolescents with HIV

The Staff are also informed about quarterly review data and briefed on Hospital performance. Staffs also attend workshops, seminars and other trainings organised by other stake holders in health.

Table 4.3: Personnel currently on training: (* Karimojong)

Duration of Number Duration bonding (to be Training Course sent for of training Source of funding effected post- training (years) training) Bachelor in Medicine and 1 5 Hospital 3 Years Surgery, 1* CPA, 1* 1 Hospital 3 Years Bachelor Science in ICT 1 3 Hospital (partly) 3 Years Diploma in Nursing, 2*, 3 5 1 1/2 Hospital 2 Years Laboratory Assistant, 1* 1 2 Hospital 2 Years Certificate In Medical Records & 1 2 Hospital 2 Years Health Information, 1* Cert in BCP, 1* 2 2 Hospital 2 Years Master in Surgery, 1 1 3 Hospital 3 Years Master in Obstetrics & 1 3 Hospital 3 Years Gyaenacology Plumbing, Cert., 1* 1 1 Hospital 2 years

 The main sources of funding for Staff Development have been external donations.  We have observed recently that some cadres, like Laboratory Assistants and Clinical Officers, are easily available and therefore only exceptionally provision is made for sponsorship. The Hospital must make continuous provision for Diploma Nurses/ Midwives since these are the more movable cadres. The Training of Tutors for the NMTS is a continuous concern of Management in order to ensure proper Staffing of the School and quality training.

Conclusion

The HMT continues investing a lot of resources both in developing and nurturing the Staff by providing dignified housing and other fringe benefits and we believe that the commitment and dedication of our Staff in the provision of care to the patients is evidenced by the out puts. The number of Staff renewing contracts has increased, therefore staff retention is contained. During the exit interviews with those leaving we perceive that the reasons for turnover are more related with personal/family reasons and career development rather than dissatisfaction with work environment or remuneration.

41 of 108 CHAPTER FIVE

HOSPITAL FINANCES

This Financial Year the Hospital managed to balance income and expenditure with a positive balance of 61,718,571/= UGX. Fortunately external donations increased as well as donations of funds and goods for the complete water supply system restoration. It still remains a challenge for the Hospital Administration to make sure that the running costs are covered. Management has to find sources from within in order to keep up with the rising costs. The income from user fees increased in this financial year as there were more patients paying the cost recovery rates, mainly via Insurance Schemes. The out patients have increased over the Financial Year. The number of admission increased as well. The PHC Conditional Grant was received 100% and the earmarked PHC Conditional Grant for drugs and surgical sundries via JMS eventually as well. Various types of external donations increased. Government support in terms of Essential Drugs has also increased during this financial year while other income for sales and services has decreased. The Hospital continues to use the financial program, FIPRO which was initiated by UCMB. It is a program for Accounting, Budget control and Cost analysis. Since many years the Hospital tracks costs per cost-centre/department, for better efficiency and timely decision making. - See the table below concerning various sources of income.

Table 5.1: Trend of Income by sources over the last 5 years, FY2013/14 to FY 2017/18

FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 INCOME UGX UGX UGX UGX UGX User Fees 216,100,950 272,439,130 366,737,426 437,219,908 549,852,350 PHC CG Hospital ¹ 529,372,125 537,666,660 536,474,193 518,675,384 444,975,777 PHC CG School ¹ 28,784,957 28,009,492 29,517,040 23,052,239 40,716,772 PHC CG HSD ¹ 35,194,103 35,000,000 35,000,000 34,578,359 32,000,000 Other School Income 136,189,483 164,022,600 190,606,550 159,185,050 260,128,000 External Donations Funds 140,272,160 195,900,000 194,163,706 204,008,341 428,869,753 (Cap. Dev’t) External Donations of 759,581,030 701,267,703 969,929,599 1,024,081,015 1,195,573,905 Funds ² External Donations 377,220,607 152,075,559 82,201,470 96,719,044 66,929,588 Goods/Services Value of EDP Drugs 75,646,673 27,298,165 21,589,271 17,225,000 35,695,082 received Received in kind for 235,769,950 301,197,959 58,924,383 105,687,004 not valued HIV/AIDS Value of Lab Reagents & included in included in included in included in included in Consumables EDP Drugs EDP Drugs EDP Drugs EDP Drugs EDP Drugs Other Income ³ 173,258,762 242,688,621 285,593,559 318,679,727 234,470,445

TOTAL 2,707,390,799 2,657,565,890 2,770,737,197 2,939,111,071 3,389,211,671

Income

The trend details of the various income sources are compared over the last five financial years in Graph 5.1. User Fees income increased by 25.8%. This is mainly attributed to more patients paying cost recovery rates. The PHC CG to the Hospital, NMTS and for PHC activities were received by 100%. The drug and surgical sundries component through PHC CG for 4th Quarter delayed a bit as JMS delivered these items later. The general support towards the Nursing & Midwifery Training School increased as compared to last year by 63.4%. Bursaries from Government and Development Partners have increased. External donations for recurrent costs have increased by 16.7%, due to the faithful support of the various support groups and benefactors. They remain the highest source of income for the

42 of 108 Hospital, guaranteeing to keep the services highly subsidised. The donations for Capital Development increased by about 224 million UGX as equipment for the water ring system was received. The value of essential drugs allocated from Government increased as compared to the previous year. External Donations of Goods instead decreased.

Graph 5.1 – INCOME SOURCES AND TRENDS

INCOME DETAILS & TRENDS FY 2013/14 - 2017/18

1,200,000,000

1,000,000,000

800,000,000

600,000,000

400,000,000

200,000,000

- Ot her Ext ernal Ext er nal Ext er nal Value of Received PHC CG PHC CG PHC CG Ot her User Fees School Don. (Cap. Donat ions Donations EDP Drugs in kind f or Hospital ¹ School ¹ HSD ¹ Income ³ Income Dev’t) of Funds ² Goods/ Ser received HIV/ AIDS

FY 2013/ 14 216,100,95 529,372,12 28,784,957 35,194,103 136,189,48 140,272,16 759,581,03 377,220,60 75,646,673 235,769,95 173,258,76

FY 2014/ 15 272,439,13 537,666,66 28,009,492 35,000,000 164,022,60 195,900,00 701,267,70 155,681,76 23,691,957 301,197,95 242,688,62

FY 2015/ 16 366,737,42 536,474,19 29,517,040 35,000,000 190,606,55 194,163,70 969,929,59 82,201,470 21,589,271 58,924,383 285,593,55 FY 2016/ 17 437,219,90 518,675,38 23,052,239 34,578,359 159,185,05 204,008,34 1,024,081, 96,719,044 17,225,000 105,687,00 318,679,72

FY 2017/ 18 549,852,35 444,975,77 40,716,772 32,000,000 260,128,00 428,869,75 1,195,573, 166,929,58 35,695,082 - 234,470,44

Graph 5.2 – User Fee / SUO (Indicates Equity or Affordability for patients to the Health Services)

User Fee / SUO 2,400 2,144 2,000 UCMB network: Average Fees/SUO during FY 2017/18 = 7,862 1,600 1,731 1,729 1,200 1,018 1,267 800 400 - FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18

Equity (affordability) refers to user fees per SUO. It refers to the amount that a patient has to pay per hospital standard unit of output. If services are equitable, then the fee per SUO must remain low, so that even the poorest of the poor can afford. Equity for Matany Hospital had an increase of 24% from the previous year. The service provided by Matany Hospital however remained equitable compared to the average fees per SUO in the UCMB network, which is 367% higher than the ones of Matany. Our services continue being highly subsidised. In addition the Hospital continues to support the poor and destitute by treating them free of charge, debiting the Samaritan Fund.

43 of 108 Expenditure

Table 5.2: Trend of Expenditure over the last 5 years, FY2013/14 to FY 2017/18

FY2013/14 FY2014/15 FY2015/16 FY2016/17 FY2017/18 Expenditure UGX UGX UGX UGX UGX Employment Cost 1,089,165,679 1,210,141,232 1,272,733,923 1,286,201,444 1,413,782,126 Administration Cost 63,336,951 74,668,272 88,239,244 114,868,920 102,940,574 Property Cost 109,970,466 75,635,695 77,111,948 96,940,736 159,541,598 Transport and Plant 192,242,875 158,340,721 157,211,109 104,949,847 175,515,900 Cost Medical goods and 681,874,764 519,121,533 471,683,899 651,339,328 824,993,184 medical Supplies Non-medical goods/ 93,545,075 57,594,327 51,494,803 55,433,780 84,138,021 suppl. PHC Activities 123,062,226 87,909,140 51,479,662 33,451,434 82,294,735 Major maintenance & 152,272,656 210,734,276 215,135,097 122,022,413 144,332,853 upkeep of buildings Staff Development 32,175,099 15,606,500 58,709,200 104,949,847 95,778,950 Cost Training School Cost 192,247,135 190,188,657 193,136,286 211,837,838 244,175,161 TOTAL 2,729,892,926 2,599,940,353 2,636,935,171 2,781,995,587 3,327,493,101

Comment: Employment Costs have increased as during FY 2017/18 there was a salary increase in average about 9.1%. Administrative Costs decreased by 12 million UGX. In the Property Cost the rise of expenditure was due to increased costs for cleaning of the wards and minor repairs of infrastructure. Transport and Plant Costs increased as fuel prices rose and more electricity is now received from the grid. Medical goods and supplies increased by about 27% due to rising costs and more patients seen. Non-medical goods/supplies were mainly food items which the Hospital provided. Expenditure for PHC activities increased during FY 2017/18 as with the help of CUAMM hard to reach areas were visited regularly. There were also several immunisation campaigns. Major maintenance and upkeep of buildings increased as well. The building of the new staff house was completed. Staff Development costs have decreased but remain still high, as management believes in developing its own staff. The cost for the Nursing and Midwifery Training School has increased but was compensated with higher income.

Graph 5.3 – Expenditure Details and Trends over the last five years

1,500,000

1,200,000

900,000

600,000 '000 UGX'000 300,000

0 Trans- Med. Non- PHC Capital Employ Admini- Property port & goods & med ical Activi- Develop NMTS ment C o st stration Cost Plant services supplies ties ment

FY 2013/14 1,089,166 63,337 109,970 192,243 681,875 93,545 123,062 184,448 192,247 FY 2014/15 1,210,141 74,667 75,636 158,341 519,122 57,594 87,909 226,341 190,189 FY 2015/16 1,272,734 88,239 77,112 157,211 471,684 51,495 51,480 273,844 193,136 FY 2016/17 1,286,201 114,869 96,941 104,950 651,339 55,434 33,451 226,972 211,838 FY 2017/18 1,413,782 102,941 159,542 175,516 824,993 84,138 82,294 240,112 244,175

44 of 108 Graph 5.4 – Trend of Efficiency over the last five years

Trend of economic Efficiency over 5 years 12,000 10,764 10,509 9,999 9,747 10,000 9,131

8,000

Recurrent Costs/SUO 6,000 UCMB network: Average Recurrent Cost/SUO during FY 2017/18 = 21,458 4,000 2013/14 2014/15 2015/16 2016/17 2017/18

Comment: Efficiency is a measure of cost per unit output (SUO). In 2017/18, the cost per SUO increased to 10,764 as compared to the previous year of 9,131. This is an increase of 1,633 or 17.9% cost per output. This was expected because the Hospital had to spent more per SUO due to rising costs and inflation. As compared to economic efficiency of the UCMB network of 21,458, the economic efficiency of the Hospital has remarkably been good.

Find in Annex 3 the Financial Report Table which is annually presented to UCMB.

Financial Year Result

FY 2017/18 ended with a positive balance of 61.7 million UGX. This is attributed due to the faithful support of the various support groups and benefactors as well as the continuation of CUAMM support mainly to the Maternal to Child Health component in the Hospital and the NMTS. There was also a grant from the OPM in support to the renovations of the NMTS as well as part sponsorships. Another intervention from the side of the Hospital Management was the containment of costs. However it remains a challenge to keep costs low. Management is further confronted with the increased costs of goods and services. Management strives to increase income through regular reports and by keeping in touch with faithful donors.

Government Intervention

As it is shown by the graphs above, Government’s support to the Hospital in the form of PHC CG has remained stable. As costs rise the actual support from government decreases year after year and the Hospital has to struggle to make up for the additional cots not covered. - The budget allocation for PHC CG has also changed as since FY 2017/18, 50% of the funds are send straight to JMS for purchase of drugs and surgical sundries. At times stock outs at JMS delay the supply of ordered drugs. However appreciation is given to the Government not only for the financial support itself, but also for the level of co-operation that continued to be good. The release of funds by the Ministry of Health and forwarded by the District Local Government were within the quarter they were meant for.

45 of 108 In the entire Karamoja Region there are, apart from Local Government, NGO’s, Schools, Health Units and a few building companies, no major employers. Therefore the vast majority of people living in this area are not able to afford cost recovery charges.

Table 5.3: Trend of Average user fees by department in the last 5 years

Average Fees FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 UGX UGX UGX UGX UGX OPD Adult & children 2,927 3,790 6,741 7,900 9,231 IP Maternity 4,777 10,135 17,776 19,205 16,875 IP Paediatric 1,396 2,434 5,744 5,400 4,202 IP Surgical Ward 32,108 52,229 60,470 81,591 91,892 IP Medical Ward 20,448 42,142 61,428 64,814 101,381 IP TB Ward 7,748 19,091 25,872 20,795 24,498

From the data in the table above the trend of user fees shows that the Hospital has been trying to keep user fees extremely low in spite of rising costs and inflation. from FY 2014/15 onwards the Hospital started Memoranda of Understanding with Health Insurances and cost recovery rates were applied to their clients. In April 2015 the BoG of the Hospital decided the increase of fees and to eliminate the fees difference for patients from within and outside the system (patients from and outside the catchment area). In table 5.3 above IP Paediatric Average Fees, as well as Maternity Average Fees dropped due to some fees adjustments for children and pregnant women.

Looking at table 5.4 below the cost recovery from the patients over the past five years in relation to recurrent cost varied from 9.69% to 19.25%. In FY 2017/18 it was at its highest ever, namely 19.25%. In spite of the higher cost recovery rate Matany Hospital services are not sustainable and can be only maintained from donations, government support and of well wishers.

Table 5.4: Cost Recovery Trend in the period FY 2013/14 to 2017/18

FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 UGX UGX UGX UGX UGX Total User fees (a) 216,100,950 272,439,130 366,737,426 437,219,908 549,852,350 Total Recurrent 2,177,184,125 2,414,683,902 2,856,690,352 2,230,135,810 2,111,108,280 (incl. staff (incl. staff (incl. staff Expenditure (b) development Cost) development Cost) development Cost) Cost Recovery Rate 9.69 12.91 16.84 18.11 19.25 = (a/b)x100

As Cost-recovery is still low the effort of management to solicit funds through programmes and donations is evident. - User Fees are captured from the various cost centres and evaluated monthly. Another factor is that often poor patients receive treatment free and the fees are downloaded on the Samaritan Fund account which is fed by external donations and then captured as income from User Fees. In FY 2017/18 the amount of 42.3 million UGX was received from the Samaritan Fund, which constitute 7.7% of the User Fees.

During FY 2017/18 there was an increase of out patients. This explains the increased income from user fees by 112.6.5 million UGX. As mentioned above we see also more patients covered by a Health Insurance for who cost recovery rates can be applied.

46 of 108 Table 5.5: Trend of indicators of efficiency in use of financial resources

FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18

UGX UGX UGX UGX UGX Maternity Ward 32 beds 36 beds 36 beds 36 beds 36 beds Cost per bed 6,050,123 6,041,099 8,404,804 10,047,404 14,084,662 Average Cost per inpatient 102,762 111,299 149,714 154,049 209,871

Cost/SUOop 212,209 214,994 211,870 252,944 256,486 Paediatric Ward 112 beds 88 beds 88 beds 88 beds 88 beds Cost per bed 3,032,294 4,163,946 4,077,601 5,364,747 7,217,037 Average Cost per inpatient 76,164 76,594 91,282 103,281 145,365

Cost/SUOop 212,209 214,994 211,870 252,944 256,486 Surgical Ward 41 beds 41 beds 41 beds 41 beds 41 beds Cost per bed 3,899,209 4,777,033 6,629,408 8,879,884 11,460,494 Average Cost per inpatient 227,297 240,955 264,635 328,291 330,204

Cost/SUOop 212,209 214,994 211,870 252,944 256,486 Medical Ward 41 beds 41 beds 41 beds 41 beds 41 beds Cost per bed 4,722,047 4,872,256 5,667,765 6,803,168 9,032,922 Average Cost per inpatient 171,179 177,725 223,226 207,846 292,277

Cost/SUOop 212,209 214,994 211,870 252,944 256,486 TB Ward 58 beds 44 beds 44 beds 44 beds 44 beds Cost per bed 1,494,001 2,315,322 2,332,332 4,593,103 3,618,047 Average Cost per inpatient 198,288 262,283 310,978 379,168 305,010

Cost/SUOop 212,209 214,994 211,870 252,944 334,080 Cost per OPD activity 7,217 7,631 12,162 13,509 16,900

(NB: Total SUOop = Total OP + 15*IP + 5*Deliveries + 0.5*Total ANC + 0.2*Total Immunisation) Source: UCMB

Above table 5.5, shows in general a trend of rising costs. It is not possible with the inflation and rising costs to be more efficient in saving funds for activities and services. The cost per bed reduces when more beds are provided. Average cost per inpatient rise when less patients are seen and the total cost is divided by less patients. In all the wards the cost per inpatient showed a steady rise. Exception for this year is TB Ward. The cost per OPD activities has risen by 25%. In spite of cost containment efforts of the Hospital Management, the recurrent and also the total costs for FY 2017/18 increased between 23.7- 19.6 %. The PHC Conditional Grant which remained constant for a couple of years has not increased equally with the rising costs. Therefore the contribution of the PHC CG to cover the total cost has reduced from 20.72% to 15.56% in comparison to the total Cost. (see Graph5.5 below) Graph 5.5 – PHC CG contribution towards total expenditure

% of PHC Conditional Grant over the last five FY's vs. expenditure 100.0% 80.0% 60.0%

40.0% 21.74% 23.10% 22.79% 20.72% 15.56% 20.0% 0.0% FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18

47 of 108 In table 5.6 below, the average cost of treating three of commonest disease conditions are compared to what is charged to patients (This remained constant).

Table 5.6: Cost and User fees for three common diseases seen in Outpatient Department and treatment of same diseases during severe manifestation in the Children’s Ward

Average Average Amount Amount Estimated charged charged as % Disease cost to the of cost Hospital (A) (B) (B/A)x100 Out patient department Malaria in children < 5 years 21,000 2,000 9.5% Pneumonia/URTI in children < 5 yrs 27,000 3,000 11.1% Acute diarrhoea in children < 5 years 2,000 plus 1,000 if 21,000 9.5% to 14.3% Antibiotic is needed Admitted in Paediatric Ward Malaria in children < 5 years 150,000 5,000 3.3% Pneumonia in children < 5 years 225,000 5,000 2.2% Acute diarrhoea in children < 5 years 137,000 5,000 3.6%

In the following tables 5.7 and graph 5.6 the possibility of sustaining the current level of services in the absence of PHC CG and donor funding is shown. In table 5.8 and graph 5.7 the sustainability ratio changes in the absence of donor funds but if PHC CG continues at the current level. (NB: This is the extent to which the Hospital is able to meet recurrent expenditures from locally raised revenues- user fees plus any other local sources of income)

Table 5.7: Trend of sustainability ratio of the hospital in absence of both donors and PHC CG funding in the last 5 years (Local Revenue being only user fees and other locally raised funds e.g. IGA, excluding government funds)

FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 Table 5.7 UGX UGX UGX UGX UGX Total Local 389,359,712 515,127,751 652,330,985 755,899,635 784,322,795 Revenues (a) 2,177,184,125 2,414,683,902 2,856,690,352 Total Recurrent 2,230,135,810 2,111,108,280 (incl. staff (incl. staff (incl. staff Expenditures (b) development Cost) development Cost) development Cost) Sustainability 17.46 % 24.58 % 29.96 % 32.73 27.46 Ratio = a/b)x100

Graph 5.6 Trend of sustainability ratio in absence of both donors and PHC CG funding in the last 5 years 100.00 80.00 60.00 29.96 32.73 40.00 24.58 27.46 17.46 20.00 0.00 FY 13/14 FY 14/15 FY 15/16 FY 16/17

48 of 108 Table 5.8: Trend of sustainability ratio of the Hospital in absence of donors funding but with PHC CG funding in the last 5 years (Local Revenue refers to “in-country funding” and therefore includes user fees, PHC CG, Local Government contributions, IGAs, etc.)

Table 5.8 FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 UGX UGX UGX UGX UGX Total Local 1,122,400,220 1,303,518,460 1,253,322,219 1,332,205,617 1,562,143,344 Revenues (c) Total Recurrent 2,230,135,810 2,111,108,280 2,177,184,125 2,414,683,902 2,856,690,352 Expenditures (b) Sustainability 50.33 % 62.21 % 57.57% 55.17% 54.68% Ratio = (c/b)x100

Graph 5.7 Trend of sustainability ratio in absence of donors funding but with PHC CG funding in the last 5 years 100.00% 80.00% 62.21% 60.00% 57.57% 55.17% 40.00% 50.33% 54.68%

20.00% 0.00% FY 13/14 FY 14/15 FY 15/16 FY 16/17 FY 17/18

The previous tables 5.7 and 5.8 and Graphs 5.6 and 5.7 show clearly the vulnerability of the financial situation of the Hospital.

External Audit

Every year the Hospital carries out an external audit. Key observations and recommendations were:

 Personnel files should have all the required credentials and photographs  Stock Cards in the Technical Department Store should be regularly updated

The previous audit recommendations were mostly complied with which was stated in the Management Letter for FY ended June 2017 and others were recommended as a way forward.

Procurement

The Procurement Committee in the Hospital is the HMT. The Hospital Administrator serves as Procurement Officer. Since July 2015 a Procurement Advisor, holding a Diploma in Procurement and Logistics Management is employed. He carries out most of the purchases, which are beforehand authorised by the HMT/Administrator. The needs of the various departments are listed and brought for verification to the Administrator. The procurement procedures in the Hospital are very clear and have been satisfactory. However a Procurement Manual might be useful to be verbalized. Major procurements during FY 2017/18 were an Ambulance which arrived in September 2017. Handing over of a staff house with six units in November 2017. Equipment and installation of a new water ring supply system, (including two new water tanks a' 50 m³). Further Completion of a Kitchen for Patient Attendants, Renovation of old Patient Attendants Kitchen which was turned into an archive and IT Store, Renovation of St. Bakhita Hostel at the NMTS and renewal of the sewerage line of the NMTS. Purchase of some Dairy Goats to eventually supply goats milk to the Nutrition Unit.

49 of 108 Conclusion

It remains a challenge to contain costs with a proper utilization of resources. Resources are becoming evermore limited or rather the costs increase and income does not necessarily rise at the same level. A meagre emergency fund of the Hospital cannot be invested as at times government funds delay and there is need to always have some liquid funds available for operations. Taking these factors into account, the action plan for the next financial year(s) will focus on the following areas:

 Continue the dialogue with the Government at District and at National levels through the strengthening of co-operation, resource mobilisation and mutual trust. Secondment of more personnel through the District Service Commission would help cutting down on Employment Costs. However budget support to cover some percentage of the wage bill is preferred as it is easier to manage staff who receive their salary directly from the Hospital. The salary increase during FY 2017/18 by about 9.1% resulted in having to

find additional funds in absolute figures of 126.6 million UGX.

 Continue monitoring the usage of financial and material resources at departmental levels with more involvement of the staff especially the departmental heads.

 Have monthly activity reports from the Internal Audit Department as well as reports from the IT Department presented to the HMT

 Ensure that budget controls done quarterly and external Audit is carried out annually.

 Consider to change the accounting program (FiPro) as there is no longer software support

 Follow the five year Strategic Plan approved by the BoG

 Continue keeping structures well maintained as to avoid higher costs for major renovations

50 of 108 CHAPTER SIX

HOSPITAL SERVICES

This chapter describes the activities of St Kizito Hospital Matany, with regard to comprehensive care of the patients and health of the community. The service package provided by the Hospital is sub divided into 3 sections: Preventive, Curative, and Supportive/rehabilitative services.

CURATIVE:

A. OUT PATIENT DEPARTMENT (OPD)

Introduction

OPD serves as an entry point for patients seeking services from Matany Hospital. According to its established function in the District Health System, the Hospital should offer to the public outpatient consultations of first contact exclusively for the immediate catchment’s area of the Hospital (Matany Sub County), outpatient consultations of referral level (for referred patients only), inpatient and emergency services and a package of preventive and promotive services (for the immediate catchment area i.e. Bokora Health Sub District). This functional role has been commendable over the last year. Working schedule is from 08:00HRS to 18:00HRS from Monday to Friday and from 08:00HRS to 13:00HRS on Saturday.

OPD Staffing level during the financial year remained quite stable and adequate: the clinical team comprised one medical officer and three/four clinical officers fully responsible for seeing the out patients. The nursing staff level in the department has improved as compared to previous years. Since OPD is the main access point to service care provided by Matany Hospital, a well staffed and efficiently running OPD is a necessity. In April 2015 the OPD had a major restructuring with creation of OPD pharmacy. It relieved the nursing staff off the responsibility of dispensing drugs to patients. They could now concentrate more on other aspects of patient care like triage. The flow of patients and system of payment was also changed to cope with the diversity of clients’ needs.

Laboratory and radiology departments complement the functioning of OPD; in order to ensure diagnostic services, and guarantee quality of care provided to the out patients, these departments are kept functional throughout the readjustments in the OPD work schedule.

During Financial Year 2017/18 the total number of OPD attendances (without special clinics) was 25,847 an increase of 7.4% visits as compared to the previous year. Although Matany Hospital is not a referral Hospital in the region, it was observed that 32.1% of the patients were from outside the catchment area.

Graph 6.1: Illustration of OPD attendance during financial year 2017/2018

Matany Hospital OPD Attendances during FY 2017/18 5,000

4,000 Total OPD Attendances: 25,847 2,802 3,000 2,425 2,364 2,158 2,168 2,180 1,821 1,898 1,866 2,000 1,679 1,926 1,874

1,000 75 88 75 58 73 30 32 58 35 55 74 0 33 Jul-17 Aug Sept Oct Nov Dec Jan-18 Feb Mar April May Jun-18

Total Attendances Re-attendances

51 of 108 Table 6.1: Trend of Out-patient Attendance in the period 2010/11 to 2017/18

OPD Department FY FY FY FY FY FY FY FY

10/11 11/12 12/13 13/14 14/15 15/16 2016/17 2017/18 New attendance 46,429 43,458 37,712 31,055 29,675 22,096 23,570 25,161 Adults 23,215 21,726 20,407 17,470 16,704 13,907 14,177 16,294 Children 23,214 21,732 17,305 13,585 12,971 8,189 9,393 8,867 Re-attendance 2,339 1,832 1,640 2,019 2,019 1,377 506 686 TOTAL 48,768 45,290 39,352 33,0742,336 23,473 24,076 25,847 OPD plus 72,495 67,668 65,380 57,866 78,175 63,015 special clinics 87,603 89,658

The total number of outpatients including special clinics increased by 2.3% compared to last year. The population is growing coupled with increased referred patients, increases the number of OPD attendances. This year there was an increase of patients seen in special clinics of 0.4%. The Hospital has special clinics like ophthalmology, dental, surgical, gynaecological, YCC, HCT, MDT-TB, counselling, physiotherapy, orthopaedic, ophthalmic, ART, ANC, PNC and the youth clinic. These clinics offer specialised services to patients there by improving on the quality of care given. The MDR-TB clinic was started in February 2015. The clinic has enrolled 46 patients with 32 still active, 11 cured and 3 patients died. The Hospital catchment area is ever widening with more patients coming not only from Karamoja region but increasingly also from neighbouring regions of Teso, Bugisu, Lango and Western Kenya

Graph 6.2: OPD attendance Trends over the last five years

OPD attendance trends over the last five years

100,000 80,000 60,000 40,000 20,000 0 FY 13/14 FY 14/15 FY 15/16 FY 16/17 FY 17/18

Children Special Clinics Reattendants Total

Table 6.2: List of Top ten OPD diagnoses in Financial Years 2015/16 to 2017/18

FY 2015/16 FY 2016/17 FY 2017/18 1 Malaria 6,490 1 Malaria 6,507 1 Malaria 4,181 2 Pneumonia 3,802 2 Pneumonia 4,678 2 Pneumonia-cough/cold 3,048 3 GID 1,367 3 GID 1,354 3 GID 1,891 4 UTI 1,070 4 UTI 1,171 4 Pneumonia 1,781 5 Diarrhoeal Diseases 620 5 Diarrhoea 1,146 5 UTI 1,452 6 Injuries 528 6 Injuries 901 6 Injuries 878 7 Eye conditions 505 7 TB 561 7 Diarrhoea 832 8 Skin diseases 493 8 Skin diseases 552 8 Skin diseases 734 9 STDs 354 9 Eye conditions 468 9 Hypertension 648 10 Hypertension 276 10 Anaemia 380 10 TB 528

Malaria is still the top diagnosis made in OPD with majority being children. However, there is a significant decrease of 35.7% of malaria cases seen. VHTs are providing ICCM. VHTs treat malaria, diarrhoea and cough in the community. VHTs get drugs from NMS which

52 of 108 ensures that they have a constant supply of anti- malarial drugs. The routine distribution of ITNs in health facilities during the course of the year and intermittent preventive treatment among pregnant women could all have contributed to declining malaria cases. Injuries from assault, road traffic accidents, etc.. are increasing. More effort is needed to improve sanitation in the community so as to reduce on hygiene related diseases like diarrhoea, skin infections. TB and anaemia have dropped however Hypertension cases have increased.

Graph 6.3: Top ten causes for OPD Attendance in Matany Hospital during FY 2017/18

Top ten causes for OPD Attendance in Matany Hospital during FY 2017/18

Hypertension TB Skin Diseases Malaria 4% 3% 27% Injuries 5% 5%

Diarrheal D'ses 5% UTI 9% Pneumonia- cough or cold Pneumonia 19% 11% GID 12%

Graph 6.4: Top ten causes for OPD Attendance in Bokora HSD during FY 2017/18

TOP TEN CAUSES FOR OPD ATTENDANCES IN BOKORA HSD FY 2017/18 Injuries (All Other eye Pneumonia types) Conditions Urinary Tract 4% 3% 3% Infectons (UTI) Skin Diseases 4% 3% Malaria Gatro-Intestinal 40% Disorders (non- infective) 4% Diarrhoe 5% Mild Acute Malnutrition Pneumonia- (MAM) cough or cold 6% 28%

The graphic above gives an overview of the top ten causes for seeking medical care in all the 16 health facilities in the HSD. Malaria, pneumonia, mild acute malnutrition, and diarrhoeal diseases contribute the highest disease burden in the community. Hygiene related diseases still make a big percentage of causes for OPD attendance in the HSD. Relevant district authorities need to emphasise promotion of hygiene and proper waste disposal.

53 of 108 SPECIALIST OPD CLINICS –

Matany Hospital offers specialised outpatient like ophthalmology, dental, surgical, gynaecological, YCC, HCT, MDT-TB, counselling, physiotherapy, orthopaedic, ophthalmic, ART, ANC, PNC and youth clinic. The HIV/AIDS Clinic runs twice a week (Tuesdays and Fridays). The MDR-TB clinic runs on Wednesdays and Fridays. The rest of the clinics are functional from Monday to Saturday. The HCT clinic had the highest attendance of 9,138 followed by ART clinic (2,126), surgical clinic (2,042), physiotherapy clinic (1,344) and Gynaecological clinic (1,208)

Dental Clinic

The Hospital provides a limited number of dental services as seen below. Although Dental Care is one of the components of Primary Health Care, its service demand is still low from the catchment population. For this reason, employment of a dentist/oral surgeon is one of the least priorities of Matany Hospital. The senior human resource in this department is a Dental Assistant, with a certificate in dental care. During the year 258 patients were treated, an increase of 7.5% compared to last year. Pathologies treated include; dental carries, gingivitis, injuries, etc.

Table 6.3: The top three procedures done in the course of the year

No of No of No of No of No of patients patients patients patients patients Dental Procedure 5 yrs and 5 yrs and 5 yrs and 5 yrs and 5 yrs and above above above above above 2013/14 2014/15 2015/16 2016/17 2017/18 1 Tooth extraction 377 299 119 64 52 2 Dental fillings 76 80 45 29 16 3 Scaling and polishing 9 16 1 7 7

Orthopaedic and Physiotherapy

This department is annexed to general surgery. The patient flow to the orthopaedic department is either through the OPD for the outpatients, or from the surgical department, thus catering for both in and out patients. For its proper functioning, the expected staffing norm is supposed to comprise two Orthopaedic Officers and a physiotherapist. Currently the Hospital has one Orthopaedic Officer and a Physiotherapist. For quality assurance and proper follow up of patients, this team works under the supervision of the surgeon or medical Officer in charge of the surgical department. The workload in the department increased by 14%. A total of 1,195 patients were seen in the orthopaedic unit. With the improved security and motorised mobility, majority of orthopaedic cases are due to road traffic accidents and assault. Occasionally, sporadic cases of congenital abnormalities (club foot), T.B of the spine are treated. Clients for Physiotherapy are identified from all departments, and daily follow up is done for those who are admitted. Tables 6.4 and 6.5 below show the orthopaedic and physiotherapy rehabilitative work load during the year 2017/18.

54 of 108 Table 6.4: Orthopaedic procedures done from FY 2013/14 to FY 2017/18

No of patients Orthopaedic procedures done 2013/14 2014/15 2015/16 2016/17 2017/18

1 Plaster ( POP) 664 501 461 448 405 Open reduction and internal 2 177 200 205 178 173 fixation 3 Others 1,972 1,051 901 845 938

Table 6.5: Physiotherapeutic services in the Hospital in the last five years

No of patients Condition

handled 2013/14 2014/15 2015/16 2016/17 2017/18 1 Trauma 1,366 1,210 1,098 997 347 2 Degenerative 43 53 125 186 678 3 Congenital 51 53 30 49 33 Infectious 4 problems 83 71 99 200 137

HIV AND AIDS SERVICES

HIV Counselling and Testing/HCT

The regional prevalence of HIV in Karamoja is 5.3% which is lower compared to the national prevalence of 7.3% but is increasing rapidly from 1.7% in 2005. Factors contributing to this include; ignorance about HIV/AIDS, widow inheritance, polygamy, female genital mutilation especially among the Pokot, stigma, rural-urban migration where returnees who are infected from other towns come back home and spread the disease, etc. Matany Hospital, in line with the National strategy of 90-90-90 is testing and counselling all patients who turn up to the Hospital for any health services. The objective of this policy is to have 90% of individuals with HIV tested, 90% of those with HIV getting started on ART and 90% of those on ART achieve viral load suppression. Matany has been carrying out HIV testing and counselling services and has an HIV/AIDS clinic which was started in May 2005. The Hospital is also a national sentile site for HIV surveillance. In the last financial year 8,285 clients were tested which was an increase of 87% compared to the previous financial year. HIV positive clients were 64 (0.7%). The number of individuals with discordant results increased by 120% from 10 to 22. Counselling discordant couples remains a big challenge as few accept the results. The Hospital has a viral load focal person who ensures all ART client have their viral load tests done and are suppressing. The Hospital does not offer safe male circumcision services for prevention of HIV. However circumcisions for other medical related conditions are done. Procurement of ARVs and laboratory supplies is by Medical Access Uganda (MAUL). This has greatly reduced the problem of Anti-retroviral drugs and laboratory HIV supplies stock outs. The Hospital has three professional counsellors who do all the counselling. So to further boost the utilization of counselling and testing services, some staff and clinicians have undergone in service capacity building in provider initiated testing and counselling. Clinicians have also been trained on the current HIV treatment guidelines.

55 of 108 HCT services have been extended to hard to reach areas through outreaches. Staff in the clinic have been trained in adolescent HIV care. An adolescent HIV clinic was started and runs on Thursdays where infected adolescents are reviewed regularly.

Table 6.6: HIV Counselling and Testing (by gender and age group) and Relationship to Co-trimoxazole Prophylaxis and TB Detection

No of No of No of No of No of No of No of individuals individual Individual individual Individuals Individuals Individuals Category 18MTH- 5 - <10 10- <15 15 – <19 <5Years yrs yrs yrs 19-49 yrs >49 yrs Total M F M F M F M F M F M F M F H1-Number of Individuals 69 108 184 370 1,843 3,806 819 762 2,915 5,046 counselled H2-Number of Individuals 108 83 68 65 69 108 184 370 1,843 3,806 819 762 3,091 5,194 tested H3-Number of Individuals who received HIV test 108 83 68 65 69 108 184 370 1,843 3,806 819 762 3,091 5,194 results H4- Number of individuals who received HIV results 0 0 3 0 3 6 136 281 1,672 3,340 566 587 2,380 4,214 for the first time in this financial year H5-Number of Individuals 0 0 0 0 1 5 4 0 29 25 0 0 34 30 who tested HIV positive HG-H IV positive individuals with suspected 0 0 0 0 0 2 2 0 9 5 0 0 11 7 TB H7-HIV positive cases started on Cotrimoxazole 0 0 0 0 1 5 4 0 29 25 0 0 34 30 preventive therapy (CPT) H8-Number of Individuals tested before in this 0 0 0 0 0 0 17 24 249 501 56 48 322 573 financial year (re- testers) H9-Number of individuals who were Counselled and 0 0 0 0 171 185 0 0 171 185 tested together as couple H10-Number of individuals who were 0 0 0 0 123 126 0 0 123 126 Counselled and received results together as couple H11-Number of individuals with 0 0 0 0 4 6 0 0 4 6 Concordant positive results H12- Number of individuals with 0 0 0 0 12 10 0 0 12 10 Discordant results H13-lndividuals counselled and tested for 0 0 0 0 3 2 0 0 3 2 PEP H14-Safe male 0 0 0 0 0 0 0 Circumcision

Table 6.7, below shows the trend of people counselled and tested for HIV since 2014/15. Note that the percentages of the positive results shown do not depict the prevalence of HIV in the catchment population. This is because the people tested come from all over the region.

56 of 108 Table 6.7: Trend of HCT in the five Years (2014/15 to 2017/18)

2014/15 2015/16 2016/17 2017/18 Positive Negative Positive Negative Positive Negative Positive Negative 288 2,836 240 4,154 188 4,243 64 8,221 Total 3,124 Total 4,394 Total 4,431 Total 8,285 (9.2%+ve, 90.8%-ve) (5.5%+ve, 94.5%-ve) (4.24%+ve, 95.7%-ve) (0.77%+ve, 99.23%-ve)

Graph 6.5: Data of table 6.7. - Trend of HCT in five Years (2014/15 to 2017/18)

10,000

8,000

6,000

4,000

2,000

- FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 Total Positive Negative

EMTCT

The Elimination of Mother to Child Transmission (EMTCT) is a key component of the MCH activities. All mothers at the ANC are tested for HIV and all those who are positive are initiated on option B+ so as to reduce transmission to the unborn baby to less than 5%. These mothers are followed until delivery and postnatal period, their exposed infants are enrolled at mother-baby care points where EID is done and are followed up until they reach 18 months of age when their final HIV status is confirmed. They are later discharged if negative and those positive are enrolled into chronic care in the ART clinic. The Hospital is implementing the option B+ EMTCT strategy. All the mothers were counselled and tested for HIV. The number of exposed infants tested for HIV by PCR below 18 months was 33 of which only 1 tested positive. The baby who tested positive started on ARV treatment.

Turn up for the second PCR and Rapid test at 18 months is still low since most mothers cannot wean off their babies from breast feeding due to lack of alternative feeds to give the baby after one year. The current existing food insecurity is a hindrance to EMTCT. Since there is a relative risk of passing the infection through breast feeding, it is not yet established how many of the above infants could have possibly acquired the infection. As a measure to improve on the early infant diagnosis, the Hospital has put in place an EID (Exposed Infant Diagnosis) focal person who is the In-charge of ANC/PNC clinic whose role is to ensure enrolment of HIV positive mothers and their infants into the continuum of HIV/AIDS care. Male partners tested for HIV reduced by 8.4% compared to last FY. The number of HIV+ mothers who attended the post-natal clinic was only 1 out of 24 who tested positive during antenatal. To increase postnatal attendance, linkage from the Young Child Clinic has been strengthened by ensuring that all mothers returning for DPT1 attend PNC and retesting for HIV is done for all the mothers. Peer members also encourage HIV+ mothers to attend PNC.

57 of 108 Table 6.8: Performance of the EMTCT Program over the last five years

EMTCT INDICATORS 2013/14 2014/15 2015/16 2016/17 2017/18 A12-pregnant women counselled, test and 2,067 1,653 1,315 1,930 1,241 received HIV test results A 13-HIV positive pregnant women given 21 15 8 19 7 co-trimoxazole for prophylaxis A15 HIV Positive Pregnant women 36 14 24 19 14 assessed for ART eligibility A16-pregnant women who knew their HIV(+) 31 18 24 17 17 status before the 1st ANC visit EMTCT INDICATORS 2013/14 2014/15 2015/16 2016/17 2017/18 A 17-pregnant women 15 4 7 NA NA NA given ARVs for 15 0 0 NA NA NA prophylaxis (EMTCT) 16 0 0 NA 2017/18 NA A 18-0thers Specify for regimens covered 14 152 0 19 0 (Option B+) A 19-Prenant women on ART for their own 47 14 15 12 12 health A 20-Male partners tested and received HIV results 776 776 620 841 770 in EMTCT 6.2.3 POSTNATAL P2-Number of HIV + 8 56 3 2 33 mothers followed in PNC 6.2.4 EXPOSED INFANT DIAGNOSIS (EID) SERVICES E1-Exposed infants tested for HIV below 18 45 30 36 21 33 months (by 1st PCR) E2-Exposed infants testing HIV positive below 1 2 0 5 1 18 months E3-Exposed infants given Septrin for 13 21 32 48 33 prophylaxis within 2 months after birth

Mothers enrolled into EMTCT program are followed up by the counsellors and the PHC department.

ANTIRETROVIRAL THERAPY.

The ART clinic which was started in 2005 has a cumulative number of individuals ever enrolled in the clinic of 2,040. The number of new patients enrolled in HIV care last financial year was 40. The number of individuals active in the clinic is 475 who are all on ART. The ART clinic runs from 9:00am to 5:00pm every Tuesday and Friday. The client response to seek treatment is still poor. Following continuous counselling and health education, more clients are adapting to positive living. The ART clinic team also conducts support supervision to four lower level units in the HSD (Lorengechora, Lotome, Kangole and Apeitolim). Irrir Health centre has an ART clinic and the Hospital ART clinic team has been providing support supervision to them during the year. The clinic has a family social support group which holds monthly meetings, a drama group and it carries out ‘Know your child status’ activities twice a year. The workload is stressful to the assigned human resource as all of them have got other job obligations in the Hospital other than work in the ART clinic. This has posed a human resource challenge in the ART clinic. The ART clinic team includes; three clinical officers, two expert clients and three counsellors involved in the comprehensive care of clients on each clinic day. The main challenges in the clinic include; lack of nutrition support for clients, stigma, low male involvement, long distances trekked by clients, mobile community which makes

58 of 108 follow up difficult. Clients also need livelihood programmes to support them economically. All afore mentioned challenges contribute to the high loss to follow-up which stands at 56%. Currently the Hospital does not have a home based care program to trace patients to their homes because of the high cost involved in running such a program. However such a program would reduce on the high numbers who are lost from the clinic. HIV/AIDS patients are also routinely assessed for Tuberculosis and 13 clients were started on anti-TB drugs. The supply of anti-TB drugs improved since the Hospital started ordering directly from NMS.

Table 6.9: Number of PHAs started on ARV by age group and gender in the last year (2017/2018)

No. of No. of No. of No. of individuals < individuals individuals individuals Total 2years 15years and Category 2-< 5years 5-14years (24months) above Male Female Male Female Male Female Male Female Number of new patients enrolled in HIV care at this facility during the year 0 01 0 01 01 0 14 23 40 Number of pregnant women enrolled into care during the 0 11 11 year. Cumulative Number of individuals on ART ever enrolled 15 14 19 18 26 18 800 1,130 2,040 in HIV care at this facility Number of HIV positive pa- 0 0 0 0 0 0 0 0 0 tients active on pre-ART Care Number of HIV positive cases who received CPT at last visit in 0 01 01 07 05 09 165 287 475 the year. Number eligible patients not 0 0 0 0 0 0 0 0 0 started on ART Number of new patients started on ART at this facility during the 0 1 0 01 01 0 14 23 40 year. Number of pregnant women started on ART at this facility 0 11 11 during the year. Number of HIV positive patients assessed for TB at last visit in 475 the year Number of HIV positive patients started on TB treatment during 13 the year Net current cohort of people on ART in the cohort completing, 0 0 0 0 0 0 0 0 17 12 months during the year Number of clients surviving on ART in the cohort completing, 0 0 0 0 0 0 0 0 6 12 months on ART during the year Number of people accessing 0 0 0 0 0 0 13 11 24 ARVs for PEP Number of individual on ART 0 1 1 7 5 8 148 267 437 FIRST LINE (active) Number of individual on ART 0 0 0 0 0 1 17 20 38 SECOND LINE (active)

59 of 108 Mental Health

Mental health is one of the components of Primary Health Care, and Matany Hospital being a general health facility is mandated to provide mental health services among its service profile. There is no specialised psychiatric clinic run by the Hospital but the patients are taken care of in the routine OPD and in patient service delivery. Through an initiative by UCMB to improve mental health services in all hospitals in the Catholic Health Services network, all hospitals under the umbrella were expected to develop human resource capacity in mental health care. Psychiatric/mental health services are included in the routine PHC outreaches to the community. This was aimed at addressing the fact that most of the psychiatric patients are neglected in the community and therefore miss out the necessary care. Table 6.10 below, shows the disease burden of the top five psychiatric conditions in the community. Epilepsy remains the commonest condition seen in the catchment population. Its high prevalence is attributed to being a sequel of cerebral injury following childhood febrile illnesses. A few cases may be related to cerebral trauma, intrauterine infections and intrapartum complications like hypoxia. There has been an increase of alcohol abuse by 66.7%. Most depression cases are likely due to psycho–social stress factors (substance abuse, gender based violence, child abuse, extreme poverty, loss of loved ones etc) in the community. Through continued community sensitization and mental health promotion, we hope to gradually improve community attitude and perceptions towards mental health. Given the low utilization of mental health service, and also due to the fact that psychiatry is a highly specialised area in medicine, it is not a hospital priority to employ a psychiatrist. Patients who require more specialised care are referred to appropriate centres for better care.

Table 6.10: Top five mental health diagnoses

2013/14 2014/15 2015/16 2016/17 2017/18 Top five mental health No. of No. of No. of No. of No. of diagnoses Patients Patients Patients Patients Patients 1 Epilepsy 111 182 144 142 164 2 Depression 25 77 9 7 7 3 Alcohol & Drug abuse 8 25 29 9 15 Other mental health 4 22 15 5 45 54 condition 5 Dementia 1 5 1 4 3

Ophthalmology

Eye care is also one of the components of primary health care. Most disability due to eye conditions can be avoided through timely and appropriate treatment. Matany Hospital provides a wide spectrum of eye care services that includes medical treatment and eye surgery. The Eye care clinic in the Hospital is run by an Ophthalmic Assistant whose basic training/qualification is a certificate in eye care. He is able to diagnose and treat most eye conditions, screen for refractive errors and dispense spectacles with the overall supervision of the clinical team. He has been trained to carry out TT-surgery by Dr. Keith Waddel. The more specialised surgical treatment is provided through ophthalmology camps carried out by ophthalmologists from St. Benedictine Eye Hospital Tororo and Dr. Keith. During FY 2017/18, three surgical camps were conducted. Two camps were conducted by St. Benedictine Eye Hospital Tororo under the CASH program for which cataract surgery was performed in Lorengechora and Irriri. One camp was for trachomatous trichiasis conducted by Sight savers in Lokopo, Lopeei and Ngoleriet sub counties. A total of 317 Patients were operated. Cataract is the main indication for surgery. Ophthalmic Assistant

60 of 108 performed 53 lid rotations in the year including outreaches within Bokora Health Sub- District.

The pathology mix for the eye conditions includes the following; allergic and bacterial conjunctivitis, cataract, eye trauma, ectropion, active trachoma infection with some cases of trachomatous trichiasis, corneal ulcers and scarring. Due to better hygiene in the community and the regular eye camps, trachomatous trichiasis has greatly reduced. Cases of glaucoma are not common among the catchment population. Referred cases were sent to St. Benedictine Eye Hospital Tororo.

Table 6.11: Trend in numbers of Ophthalmology services over the last 5 years

2013/14 2014/15 2015/16 2016/17 2017/18

No. of uncomplicated cases treated 1,039 1,355 1,411 1,177 1,114

No. of cases operated 322 374 693 236 173

No. of cases referred 6 0 2 0 28

Utilisation of Ophthalmology services has decreased by 6.9% compared to last year.

Palliative care

Care for the terminally ill is one of the challenging tasks that Matany Hospital has to undertake. There is no Community Based Organization or Civil Society Organization providing support to the terminally ill patients in the district. Home based care for the chronically ill patients is also nonexistent, leaving the entire burden of palliative care to the Hospital. Over the last ten years, there has been a gradual increase in numbers of chronically ill patients. This trend is associated to high levels of poverty, poor health seeking behavior, increasing prevalence of HIV/AIDS and cancers. Liver cirrhosis with ascites secondary to Hepatitis B infection and excessive alcohol consumption has also become one common cause of palliation among patients on the Medical ward. The emergence of chronic diseases such as Hypertension, cancer, Diabetes and Asthma have set a new dimension of high cost implications on the Hospital since most of the affected patients are very poor and unable to afford the already subsidized charges in the OPD when they return for periodic reviews and refills. Besides providing treatment and nursing care to these patients, the Hospital provides them with food as well. The Samaritan fund set aside by the Hospital to provide support to this category of patients has not been sufficient with the little contributions to this fund sourced from friends and benefactors of the Comboni Missionaries. Resource mobilization for such essential humanitarian undertakings is progressively becoming more challenging for the PNFP hospitals. The proposed National Health Insurance scheme that should have lifted this corporate responsibility mantle from the Hospital has never come to existence. The palliative care section is run by a registered nurse counselor and two other pastoral care givers trained in Palliative care. They provide pastoral care on daily basis. A combination of palliative and pastoral care are very essential in the care of the terminally ill as they provide for both medical and spiritual support.

61 of 108 Breast and cervical cancer awareness, screening and treatment

In October and November 2017, Matany Hospital together with AFRON Oncology for Africa and Uganda Women Cancer support Organisation (UWOCASO) organised a breast and cervical cancer sensitization and treatment campaign in Napak District. A total of 515 community leaders were sensitized. These were mainly Local council committee members, elders and VHTS. Screening was conducted in three facilities of Matany Hospital, Nabwal and Lorengechora health centres. A total of 703 women were screened, 99 women had PAP smear done and 35 were found to have precancerous lesions who were treated and no woman was found with advanced cancer of the cervix. 5 staff in the district were trained in screening for cancer. Cancer screening is now a routine examination in the ANC/PNC and gynaecological OPD.

B. INPATIENT WARDS

Organization and management

Matany Hospital has got five In-patient care departments; Maternity, General Surgery, Internal Medicine, Paediatrics and TB wards. The management and organization of each ward is under the care of a diploma nurse, medical officer or specialist. They are charged with the responsibility of quality assurance in patient care and treatment, duty allocation and supervision of junior staff. The criterion for admission includes critically ill patients and those who cannot take oral treatment. During the triage process, the categories of patients who are moderately ill are kept under observation while on treatment for at least 24 hours. They are then reassessed and either allowed home on treatment or admitted for continued inpatient care. Discharge is on clinical improvement and a patient should be able to feed and take oral treatment at home. Some patients are discharged on request with full consent of the patient and care taker. This scenario is common with terminally ill patients or those for whom the caretakers feel they can find better treatment elsewhere. Under both circumstances, the patient’s charter is strictly observed for medico–legal purposes. Ward rounds are done twice daily by the clinical team, nurses and paramedics in each respective department. A general ward round is done in the morning to review all patients who spent a night in the ward. In the evening round, critically ill patients are reviewed, newly admitted patients from OPD are re assessed and patient review with laboratory results is also done. Treatment schedules used strictly follow the National Clinical Guidelines for the dosage, route and frequency of specific drugs. The Hospital also has in place some treatment protocols adopted from World Health Organization. The last FY 9,927 patients were admitted, with children’s ward having the highest admissions and contributing 44% of inpatients. Monthly admissions are distributed according to the climatic season with the busy months corresponding to the rainy season. The T.B ward had the least number of admissions. The expected number of TB cases in the catchment population is 471 patients for 2017/18. Matany Hospital treated 688 patients, a case detection rate of 146%. This is above the expected National Case detection rate of 70%. However Napak District ranks among the lowest in the country in TB management performance despite the high case finding rate. This is because the District has high losses to follow up despite the high case finding rate making it rank low. CUAMM together with STOP TB - Uganda have engaged VHTs and health assistants to follow up TB patients in the community to reduce defaulting on treatment. The identification of TB cases follows the national algorithm for TB diagnosis. History of the patients, physical examination and investigations are done to make the diagnosis.

Treatment also is according to the national TB treatment guidelines.

62 of 108 The average length of stay on TB ward has increased from 18.2 to 22 days. In the past the Hospital implemented hospital based DOTS where patients were discharged after completing the intensive phase of treatment of two months. This led to long durations of stay on the ward but reduced defaulting rates. The National T.B treatment protocols recommend two weeks of in-patient treatment and then allow patients back home to continue with CB DOTS. The Hospital is implementing this guideline which has led to reduction in the average length of stay on ward unless they are critically ill. However this increases defaulter rates since many patients are lost to follow up thereby increasing a risk for MDR-TB. Patients who default are traced with the help of VHTs and health assistants. Table 6.12 below shows the various in-patient indicators for the respective departments.

Table 6.12: Utilization indicators per ward and for the Hospital for 2014/15 – 2017/18

Surgical Medical WARD 2014/15 2015/16 2016/17 2017/18 WARD 2014/15 2015/16 2016/17 2017/18 (41 Beds) (41 Beds) Patients Patients 1,128 1,170 898 1,172 1,033 838 1,138 888 Discharged Discharged Duration of stay Duration of stay 16,024 21,888 19,151 18,049 10,963 10,458 12,324 11,891 (No. of days) (No. of days)

Avg. duration of Avg. Length of 14.2 18.7 21.3 15.4 10.6 12.5 10.8 13.4 stay (No. of days) stay (No. of days) BOR 107% 146% 128% 121% BOR 73% 70% 82.4% 79.5% Turnover Interval Turnover Interval -0.9 -5.9 -4.6 -2.6 3.9 5.4 2.4 3.5 (No. of days) (No. of days) Throughput per Throughput per 28 29 22 29 25 20 28 22 Bed (No. of pts) Bed (No. of pts) Paediatric Maternity WARD WARD 2014/15 2015/16 2016/17 2017/18 2014/15 2015/16 2016/17 2017/18 (36 beds) (88 beds) Patients Patients 4,217 3,677 4,333 4,062 1,790 1,800 2,177 2,171 Discharged Discharged Duration of stay Duration of stay 27,600 29,876 28,725 28,196 12,060 13,703 14,695 14,660 (No. of days) (No. of days) Avg. duration of Avg. duration of 6.5 8.1 6.6 6.9 7.4 7.6 6.8 6.8 stay (No. of days) stay (No. of days) BOR 85.9% 93% 89.4% 87.8% BOR 91.8% 104.3% 111.8% 111.6%

Turnover Interval Turnover Interval 1.1 0.6 0.8 1.0 0.6 10.3 -0.7 -0.7 (No. of days) (No. of days) Throughput per Throughput per 48 42 49 46 46 20 25 25 Bed (No. of pts) Bed (No. of patients)

T.B Adults OVERALL WARD 2014/15 2015/16 2016/17 2017/18 Indicators 2014/15 2015/16 2016/17 2017/18 (44 beds) (250 beds) Patients Overall 438 445 478 475 85.3% 92.2% 91.6% 91.2% Discharged B.O.R No. of patient Turnover 11,221 8,229 8,706 10,433 3.1 0.9 1.0 1.0 days interval Avg. Length of Throughput 25.6 18.5 18.2 22 33.8 31.7 36.1 35.1 stay (No. of days) per bed Avg. Length BOR 69.8% 51.2% 54.2% 65% of stay 9.2 10.6 9.3 9.5 Turnover Interval Total 11 17.7 15.5 11.9 77,868 84,154 83,601 83,229 (No. of days) Inpatient Days Throughput per 6 10 11 11 Bed (No. of pts)

63 of 108 The general average length of stay has a little increased from 9.3 to 9.5 days. Surgical ward had a significant reduction in the duration of stay of 15.4 days. However medical ward, TB and children’s wards had a rise in the duration of stay. Maternity maintained the number of days patients are admitted on the ward. The bed occupancy rate slightly decreased by 0.4%. Surgical ward still has the highest bed occupancy rate (121%) because the patients stay long (15.4 days) yet the beds are fewer compared to the number of patients admitted meaning that some miss beds. However stable orthopaedic cases on traction who would be on surgical ward are utilising the free rooms on Paediatric ward. Surgical ward has the least turn over interval of -2.6 days because of the many patients admitted, few beds and long duration of stay. Surgical ward has a long duration of stay despite the reduction in gunshot cases. This is because of the many orthopaedic patients who have fractures secondary to trauma. Trauma mainly follows; road traffic accidents from commercial motorcycles which are used for transport, drunk driving, over speeding etc. Other causes of trauma are domestic violence especially secondary to alcoholism and fights in drinking places. TB ward beds are the least utilised (throughput per bed), with 11 patients using a single bed in a year and has the highest number of days between patients (turnover interval) of 11.9 days.

Table 6.13: Top 10 causes of admission

Cause of Admission Cases Cause of Admission Cases Genital urinary system 1 Malaria 2,007 6 422 diseases (non-effective) 2 Pneumonia 933 7 Injuries (all types) 391 3 Anaemia 561 8 Respiratory Infections 299 4 TB 643 9 UTI 265 Other cardiovascular 5 Diarrhoeal Diseases 473 10 196 diseases

Table 6.13 above and the graphic below show the top ten causes of admission in Matany Hospital. The pattern of causes of admission is similar to that of cases seen in OPD. Few RTIs are admitted because most are simple illnesses and are treated as out-patients. Only the more serious chest infections like pneumonia are admitted. Malaria remains the leading cause of admission contributing 20.3% of total in-patients. This is followed by Pneumonia and anaemia. Management of anaemia possess a big challenge because of poor supply of blood from the national blood bank. Major causes of anaemia are infections like malaria, obstetric bleeding in pregnant women and cancer.

Graph 6.6: Ten top causes of admission during FY 2017/18

Ten top causes of admission during the FY 2017/18 Other Respiratory cardiovascular Infections UTI diseases Malaria 4% 4% 4% 34% Injuries (all types) 6% Genital urinary system diseases (non-Diarrhoeal effective) Diseases TB Pneumonia 5% Anaemia 8% 11% 15% 9%

64 of 108 The Graphic 6.7 below shows the top causes of mortality in Matany Hospital. Liver disease, Tuberculosis, cardiovascular diseases and anaemia are among the leading causes of mortality. Tuberculosis is associated with other comorbidities like HIV and malnutrition. Alcoholism and hepatitis B infection have contributed to increase in liver diseases and mortality. Prematurity with its complications is a major cause of neonatal deaths.

Graph 6.7: Top causes of death during FY 2017/18

Ten top causes of death during FY 2017/18 in Matany Hospital

Gastro- Hypertension Acute renal Intestinal (all cases) failure Bleeding 6% 5% Liver diseases Premature 8% 22% baby (condition that require TB management 13% 8% Hepatitis B Respiratory Other 8% Cardiovascular Infections Anae mia Diseases (other) 10% 8% 12%

Table 6.14: Trends of the top causes of death in the Hospital

TOP 10 CASE FATALITY RATES A B Case Fatality Rate List Causes of Mortality No of Disease Total No of cases of (A/B) x 100 during the Financial Year specific deaths the disease admitted 1 Liver diseases 48 175 27.43% 2 TB 26 545 4.77% 3 Other cardiovascular diseases 26 208 12.50% 4 Gastro-intestinal bleeding 16 31 51.61% 5 Hepatitis B 16 67 23.88% 6 Anaemia 16 270 5.93% 7 Respiratory infections (other) 15 153 9.80% 8 Hypertension (all cases) 12 146 8.22% 9 Acute renal failure 10 32 31.25% 10 Pyrexia of Unknown origin 9 24 37.50%

Comment: Gastro intestinal bleeding, renal disease, liver disease and hepatitis B have high case fatality rates.

Maternity Ward

Maternal child health is one of the quality indicators in Matany Hospital. Unfortunately the reproductive health indicators in Karamoja region are among the worst in the country. This is attributed to the fact that quite few mothers seek medical attention and most of the society is still conservative to traditional medicine and birth attendants. The number of ANC first visits was 1,241; an increase of 6.7% from the previous financial year. Attendance for ANC fourth visit dropped from 744 to 655, a decrease of 12%. Two health facilities within the catchment area of the Hospital recruited midwives which increased maternity services to women.

65 of 108 Most mothers come late for the first ANC visit with some reporting in the third trimester. The dropout rate between the first and fourth antenatal visits is 47%. This is lower than the national average of 47.6% according UDHS 2016. The expected number of pregnant women in the catchment area (Matany sub county) was 1,174 but 1,241 women attended the first ANC. This made the first ANC coverage of 105%. The distribution of insecticide treated mosquito nets has greatly attracted mothers to ANC. The clinic is run by registered nursing officer. Mothers receive all ANC services in one place. The Hospital also has mother-baby care points in YCC, ANC and in Maternity.

Post-natal attendance has increased. The number of post-natal mothers seen was 918 which was an increase of 13.3% from last year. Of the 1,283 mothers delivered in the Hospital, 71% returned for PNC. Continuous sensitisation of mothers is needed to increase awareness about maternal health services. There is also an effort to use TBAs as change agents to refer mothers who go to them to seek better services at health facilities. Table 6.15 below shows some ANC and post natal care indicators.

Table 6.15: Antenatal and Postnatal indicators

ANTENATAL 2013/14 2014/15 2015/16 2016/17 2017/18 A1- ANC 1st Visit 1,299 1,289 1,386 1,163 1,241 A2- ANC 4th Visit 601 800 759 744 655 A3- Total ANC visits new clients + Re-attendances 5,004 4,859 3,707 3,526 3,890 M- ANC Referrals to unit 194 158 131 709 516 A5- ANC Referrals from unit 0 18 44 0 1 POSTNATAL P1- Post Natal Attendances 663 765 582 796 918 P2- Number of HIV+ mothers followed in PNC 8 56 13 45 1 P3- Vitamin A supplementation 695 641 1,118 1,157 918 P4- Clients with pre-malignant conditions for breast 0 0 0 0 0

Comment: Postnatal attendances have increased compared to last year.

Maternity Admissions:

Table 6.16: Maternity ward admission – (Deliveries and neonatal outcomes)

Deliveries and Births indicators 2013/14 2014/15 2015/16 2016/17 2017/18 Total Admissions for delivery 1,060 1,164 1,118 1,161 1,283 Deliveries in unit 1,060 1,164 1,118 1,161 1,283 Normal delivery 815 852 833 863 907 Abnormal delivery (incl C/S) 245 312 285 324 376 Live birth in units 1,052 1,137 1,080 1,119 1,293 Babies born with low birth weight (<2.5Kgs) 149 139 139 186 221 Fresh Still births in unit 14 +7 16 27 26 26 due to HEV Macerated still births in unit 14 11 11 17 17 Newborn deaths (0-7days) 15 45 40 28 37 FSB died in hospital (FHS heard before del) N/A 23 3 2 Maternal deaths 7 +16 due to HEV 4 2 3 2 For Live Births Full term Normal wt 903 967 947 960 1062 Full term Low birth wt 149 127 139 201 114 Premature 76 43 69 89 107 For Caesarean Sections Elective C/S 34 40 41 27 46 Emergency C/S 211 228 211 297 330 Total C/S 245 268 252 324 376 C/S as % of Total deliveries 23.11% 23.02% 22.54% 27.65% 29.30% Emergency C/S as % of all C/S 86.12% 85.07% 83.73% 91.67% 87.76%

66 of 108 During the Financial Year, the number of deliveries in the Hospital was 1,283, with an increase of 122 deliveries from the previous FY. 907 of the deliveries were by spontaneous vaginal delivery, while 376 were by caesarean section. The macerated still births were 17, while Fresh Still Births were 26. Only two mothers lost their babies in the Hospital, the rest (24) of the FSBs did not have active foetal heart beats at admission. The major causes of intra uterine foetal deaths were infections and antepartum haemorrhage. Upon admission of a mother into labour ward, labour is managed according to the recommended guidelines by the Ministry of Health, and closely monitored by the midwife using a partograph, which is plotted for each mother in active labour. The doctor attached to Maternity ward periodically reviews mothers in labour, and makes necessary interventions as indicated. The medical officer consults the specialist where there is need. All caesarean sections are sanctioned and performed by the doctor on duty in maternity ward or the doctor on call.

Table 6.16 on the previous page gives a summary of deliveries conducted in the Hospital during the period under review.

A Fresh Still Birth is a baby delivered with the skin intact and not macerated, indicating that the death occurred within 24 hours before delivery. It is a quality indicator of obstetric services. Total Still Birth Rate takes into account all the foetal deaths while the Fresh Still Birth rate takes into account foetal demise in the hospital after admission (or shortly before admission and is delivered within less than 24 hours of admission). For FY 2017/18 the Total Still Birth Rate was 3.4% (43), an increase of 0.1% compared to the previous year (3.3%). The fresh still birth rate in the hospital of babies admitted with foetal hearts was 0.2%.

Caesarean Sections

Graph 6.8: Trend of deliveries over the last five years

Norm. Delivery vs. CS over the last five years 1,500 1,244 1,207 1,158 1,283 1,060 933 1,000 815 852 833 837

500 376 324 245 268 252

- FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18 Total adm. Normal Caeserean for delivery Delivery Secion

During FY 2017/18 the Hospital caesarean section rate as a percentage of total deliveries was 29%. Matany Hospital receives many referrals all over Karamoja including western Kenya, most of these mothers deserve to deliver by c/section. Caesarean section accounts for the greatest percentage (20%) of major operative procedures done in the Hospital. The main indications for C/S were:

1. Obstructed labour 6. Severe oligohydromnios 2. Foetal Distress 7. Poor progress of labour 3. Ante partum haemorrhage 8. Cord prolapse 4. Cephalopelvic disproportion 9. Malpresentation and lie 5. Previous C/S section (2 or more) 10. Maternal distress

67 of 108 Maternal deaths

Pregnancy and child birth are expected to be a pleasant experience for the mother, the baby and the community. It is not expected that any mother should die during pregnancy and child birth. However, a number of unfortunate circumstances have led to the occurrences of the unacceptable phenomena. Three delays are responsible for the cause of a maternal death, whenever it occurs; the delay by the mother to make a decision to seek medical attention, the delay to get the health facility; and the delay to initiate the correct management/procedure once at the health facility. During FY 2017/18, two maternal deaths occurred in the Hospital. One death was of a mother referred from Kapenguria - Kenya through Amudat Hospital with severe septicaemia following post abortal sepsis, the second was referred from due to puerperal sepsis with a brain abscess. Maternal death audits were done as per the Ministry of Health recommendation using the standard guidelines. Each of the events was reported to the District Health Office and Ministry of Health HMIS data bank.

Treatment and care of Gynaecological cases:

A section in the maternity ward is designated for the treatment and care of gynaecological cases. The common gynaecology cases for admission include; abortions, ectopic pregnancies, tubo–ovarian masses, dysfunctional uterine bleeding, fibroids and malignancies. Cases of birth related injuries are occasionally hospitalised with most of them being mothers who delivered in villages or referred from lower level health units in the neighbouring districts. The Hospital has an obstetrician/gynaecologist to guarantee specialised care for mothers so as to minimise maternal deaths. The specialist plays a role in bed side teaching and mentorship of the midwifery trainees, midwives and junior doctors.

The high caesarean section rate (29%) in the Hospital is due to referrals from other health facilities. Graphic 6.9 below shows a comparative analysis of the provenance of mothers who underwent caesarean section over the last five years. 83% of the mothers who underwent C/S were from Bokora HSD/Napak District while the remaining proportion was from Moroto, Kotido, Katakwi, Nakapiripirit and others.

Graphic 6.9: Provenance of women who underwent CS in Matany Hospital in the past five years

From this analysis, it is noticed that less patients came during FY 2017/18 for Caesarean Sections.

68 of 108 The total number of supervised deliveries in the district was 4,774. Out of which 1,283 were in Matany Hospital while the remaining 3,461 were in the Lower level health units. Therefore Matany Hospital contributed 27% of the supervised deliveries. The overall percentage of supervised deliveries in Napak was 64%.

C. OPERATING THEATRE

One of the busiest and most expensive departments in the Hospital is the operating theatre. Due to its efficiency and reliability, workload of Matany’s operating theatre is increasing. We perform both elective and emergency surgeries. Elective surgery is one which is planned and done at the convenience of the patient and surgical team while Emergency surgery is that which if not performed urgently, the patient’s health would be severely compromised and may lead to fatality. Operating theatre works 24hrs due to the ever constant availability of water and electricity. A wide range of major and minor surgical procedures are carried out in the theatre as depicted in the data provided below.

Table 6.17: Surgical procedures done in the course of the year

Number of Proportion No Top ten surgical procedures done Patients % 1 Caesarean Section 376 20.3%

2 Debridement and care of wounds and skin grafting 238 12.8% 3 Abscess Incision and Drainage 161 8.7% 4 Minor orthopaedic surgery 90 4.8% 5 Laparotomy 144 7.8% 6 Evacuations 125 6.7% 7 Herniorrhaphy 89 4.8% 8 Orthopaedic Surgery 22 1.2% 9 Other major procedures 137 7.4% 10 Other minor procedures 513 25.5%

The key indications for surgery over the last five years are seen in table 6.18 below.

Table 6.18: Trend of surgical activities in the period from 2013/14 to 2017/18

2013/14 2014/15 2015/16 2016/17 2017/18 Major operations (incl C/S) 1,047 714 650 685 909 Emergencies 516 282 222 294 404 Emergency Op as % of total 49.3 39.5% 34.2% 42.9% 44.4% major operations Minor operations 1,226 1,432 956 782 986

The number of operations done in FY 2017/18 was 29% more than those for the last financial year.

69 of 108 D: DIAGNOSTIC SERVICES

Laboratory

By the end of June 2018, the human resource in our Laboratory included four Laboratory Technicians and four Laboratory Assistants. The Laboratory is a very busy department in the Hospital with a diagnostic role to both the outpatients and inpatients. The staffs were able to cope with the increased workload. They maintained a 24-hour on call service throughout the year. The capacity of the laboratory to carry out some tests like histopathology, culture and sensitivity is still lacking, thus samples for these tests have to be sent to Kampala.

The Laboratory acquired new diagnostic machines during the past two years. These include; GeneXpert, chemistry analysers (Humastar 200 and Hemolyte), Humacount and CD4 FACS count, PIMA and Selexon Poct for screening Hepatitis B. These machines have increased the productivity of the laboratory, reduced the turnaround time of results and provided a wide range of investigations for clinicians to request. The laboratory was also extended to create more needed space. It joined the SLAMTA/SLIPTA program and was assessed by Central Public Health Laboratories. It is a star 2 laboratory, an improvement from star 1 of last year. This program helps to improve the quality of the laboratory services.

Table 6.19: Trend of Laboratory testing workload in the period 2013/14 to 2017/18

FY FY FY FY FY Type of laboratory test 2013/14 2014/15 2015/16 2016/17 2017/18 Blood smear for Malaria parasites 19,127 14,752 12,054 16,296 15,660 Blood smear for other purposes 49 10 21 222 144 WBC Count (total and differential) 4,306 3,524 6,782 8,004 7,171 Sputum smears (specific MT/a specific) 3,998 3,797 2,449 2,073 1,525 Urethra, vaginal smears & pus smears 585 276 298 252 214 Haemoglobin estimations 9,343 11,316 9,285 8,577 11,713 PCV 0 0 11 0 0 Sickling Test 81 14 48 83 178 ESR 923 111 33 155 438 Blood grouping and X-Matching 7,705 7,823 7,887 5,095 8,004 Urine examination 3,972 4,230 3,182 5,054 4,723 CSF examination 89 143 142 96 82 Other body fluid examinations 0 288 28 43 214 Stool examinations 622 854 862 240 572 Widal test 2,137 782 595 368 0 VDRL 5,460 2,327 4,717 6,097 8,427 Serum Creatinine 1,158 1,295 1,422 2,382 1,461 Blood Glucose 472 794 265 263 219 Pregnancy test 588 630 527 772 773 HIV test 10,314 10,253 10,754 11,479 15,911 Hepatitis B. 2,033 2,368 4,722 8,554 5,652 SGOT 1,315 815 1,277 5,862 2,487 SGPT 1,315 802 1,478 5,449 2,360 Other 7,625 16,547 16,780 55,581 25,228 TOTAL 83,217 83,751 85,619 143,754 113,156

As standard it is recommended that each patient should at least have one investigation done in the laboratory so as to guide the clinicians in making a correct diagnosis. This limits the tendency by Clinicians to treat patients by giving the best guess treatment.

70 of 108 Graph 6.10: Average Laboratory Investigations requested per patient

Graph 6.10 above shows that over the last five years, the standard of at least an investigation per patient was achieved. In 2017/18 each patient had an average of 3.2 investigations done.

Blood transfusions

Most blood supply to the Hospital was from Regional Blood Bank (MRBB), supplied on request. Nakasero blood bank supply was not reliable last year because of the blood bank staff reluctance to honour our blood orders. The blood from Nakasero is most times delivered by air, thanks to Mission Aviation Fellowship (MAF). The Quality Assurance Team from MoH strongly advised the Hospital to stop local blood collection and screening as the Hospital has not got the capacity to do PCR testing for HIV in window period. In view of the cost implications of transporting blood from Nakasero and Mbale, there is urgent need to establish as a short term intervention a blood collection centre and eventually a regional blood bank in Karamoja to cater for the needs of blood transfusion services in the Regional Referral Hospital Moroto and the four general hospitals and health centre IVs in the region. During FY 2017/18 the total number of Blood Transfusions was 1,609 which was a decrease of 19.9% compared to the previous year (2,008).

Graph 6.11: Blood Transfusion Services

Blood Transfusion in Matany Hospital during FY 2017/18

200 179 165 Total: 1,609 169 156 169 147 160 135 134 134 113 120

80 55 53 40

0 Jul- Aug Se p O ct Nov D e c Jan- Feb Mar Apr May Jun- 17 18 18

NBB/MBB - 100%

71 of 108 The main indications for transfusions were anaemia due to severe malaria and haemolytic anaemia due to septicaemia especially in children while in adults the main reasons for transfusions were gynaecological and obstetric emergencies, surgical interventions, malaria and cancer patients.

IMAGING SERVICES

X-Ray Investigations

By the end of June 2018, the human resource in our X-Ray Department included two Dark Room Assistants, who were trained on the job and have gained a lot of experience over the years and one Certificate Nurse. The number and quality of X-rays taken still remained high attributed to the competence of our personnel.

Table 6.20: X-ray examinations done over the last seven years in the Hospital

Year 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Chest 3,296 3,065 3,407 3,410 2,693 4,544 5,133

Plain Abdomen 106 156 159 150 118 219 242

Barium Enema 1 5 8 3 12 15 17

Barium Meal 12 33 30 47 36 72 99

Traumatology 1,321 1,562 2,278 2,004 1,788 2,788 2,453

Skeletal 854 814 863 904 1,049 1,930 3,026

Urogenital 0 0 0 0 0 0 0

TOTAL 5,590 5,635 6,745 6,518 5,696 9,568 10,970

It remains a challenge to get trained personnel and at the same time to keep personnel cost low. Over the years a higher demand for x-rays and ultrasound was observed as clients are referred from different Health Units in Karamoja for these investigations. This proves that the staff in the department who were trained in the past by visiting radiologists have gained great experience. The staff also attend annual conferences organised by the radiologists Association of Uganda.

Graph 6.12: Trend of x-ray examinations over the past five years.

Trend of x-ray examinations over the past five years 13,000 10,970 11,000 9,568 9,000 6,745 6,518 7,000 5,000 5,696 3,000 2013/14 2014/15 2015/16 2016/17 2017/18

72 of 108 Ultrasound

The Hospital continues to rely on the senior x-ray attendant who had been trained on the job some years ago in order to guarantee this service. He is advancing his skills by self motivated studies on the subject. He has had training in Italy in operative ultrasound scan.

Table 6.21: Ultrasound examinations done over the last five years in the Hospital

Year 2013/14 2014/15 2015/16 2016/17 2017/18

Obstetrics 1,442 983 1,462 3,382 2,866

Gynaecologic 911 855 981 1,597 2,347

Liver, Spleen 1171 2068 1,584 1,961 2,940

Abdomen 3393 2061 2,289 3,579 4,789

Urogenital Organs 439 460 362 586 880

Heart 567 442 259 302 618

Tissue 910 759 526 933 1,511

TOTAL 8,833 7,628 7,463 12,340 15,951

No. of Patients 6,211 4,339 4,799 8,960 10,242

Graph 6.13: Trend of ultrasound examinations over the past five years

Trend of ultrasound examinations over the past five years 15,951 16,000 12,340 12,000 8,833 7,628 8,000 7,463 4,000

0 2013/14 2014/15 2015/16 2016/17 2017/18

Pharmacy

The Hospital has a cool and dry, burglar proof, and well organized storage space for drugs in the General Store while stock for regular consumption in the various departments is kept in the hospital/Dispensing Pharmacy. The pharmacy is headed by the PNO who oversees daily drugs and supplies logistics. The Hospital does not have a qualified pharmacist as yet. The head of department makes orders using JMS ordering forms whenever the minimum levels of stock are reached and stock out of essential drugs are rare. Stock taking exercise is done half yearly and expired drugs discarded according to recommended standards. We have not registered any other loss of drugs apart from expired drugs. Drugs are ordered from the various departments and are kept in the department drugs store managed by the department in-charge. Treatments to patients are administered by qualified Staff and are carried out within the department itself. Regular treatment schedules are kept as per doctors’ orders and patients are very compliant with this regiment of administration.

73 of 108

Drugs are ordered by the Ward In-charge for the routine treatments. Special/expensive treatments (Ceftriaxone IV etc.) need to be authorized by the MS and a special order form has been designed for it. During restructuring of the OPD, a pharmacy was created to improve on drug management and service to patients. Two staff are managing it. The Hospital is under SPARS programme and is being supervised by the Diocesan Medicines Supervisor. The assessment was done in February 2018 and Matany scored 97% which was an improvement from 93% of last year. There are continuous quarterly assessments under the SPARS programme.

Table 6.22: The ten most used drugs in our Hospital are:

S/N Injectables Tablets 1 Ampicillin Paracetamol 2 Frusemide Ampiclox 3 Gentamycin Amoxicillin 4 BenzylPenicillin Multivitamins 5 Diclofenac Metronidazole 6 Metronidazole Ibuprofen 7 Ceftriaxone Cloxacillin 8 Ciprofloxacin Folic acid and ternous sulphate 9 Cloxacillin Vitamin B complex 10 Ranitidine Erythromycin

The total expenditure on drugs during this FY was of about 317,742,391/= UGX plus donated ARV drugs. The Hospital is grateful to the Ugandan Government which supports the Hospital with PHC CG specifically for drugs. The amount of 293,200,372/= UGX is available annually at JMS for the purchase of specific drugs and surgical sundries.

Drug expenditure is significant and the possibilities of economising are related with drug prescription practices by the clinicians. Proper history taking, examination and right investigations help to make the correct diagnosis and this prevents poly pharmacy and ensures good quality service provided to patients hence also reduces expenditure on drugs. The unavailability of drugs in JMS at times is another factor which may increase hospital expenditure since drugs out of stock in JMS means to look for important/essential drugs in private pharmacies always at a higher cost.

The above mentioned drugs are regularly monitored along with Quinine Tabs and injectables, syrups and creams, ophthalmic drugs, insulin and reagents for the laboratory. The monitoring tools used are the stock keeping cards and physical count done by the Dispenser and this has been effective in preventing stock outs of essential drugs.

74 of 108 CHAPTER SEVEN

HOSPITAL SUPPORT SERVICES

The services supporting the Hospital running are: Administration and medical records, domestic services, General Store and food distribution to extremely vulnerable individuals and chronically ill patients, and ambulance service. The technical services are provided by the Technical Department which carries out all the necessary maintenance and renovation and raising new structures that take place in the Hospital. The mortuary and burial service is another supportive assistance to the community.

A) Administration and Medical Records

The Administration Department is staffed with sixteen employees. The Administrator/ CEO supervises the accounts department with one senior accountant, one Bachelor in Business Administration who is the Internal Auditor and two accounts’ assistant, four cashiers (two in OPD and two for the Inpatient Department), the General Office with one secretary and one office attendant, the HR and ICT Department. The supervision of technical personnel, procurement and logistics are under the responsibility of the Administrator with the help of the In charge of the Technical Department and the Procurement Advisor. He is also exercising the function of communication officer. The stores of the Hospital instead are under his responsibility but its supervision is delegated to different Officers. The Stores and basic accounting procedures are clearly described in the Financial and Material Resource Manual.

HMIS Data are compiled by the HMIS Focal Person and one assistant. The data is computerised following the HMIS formats as required by the MoH. Reports are regularly produced and are verified by the Medical Director. Then they are sent to the DHO and copied to the MoH. Since July 2013 the information concerning health services are automatically uploaded to the electronic system DHIS2. This is a system that handles all the health related data which is controlled by the MoH.

B) Domestic Services

The domestic service comprises catering and domestic store keeping, food preparation and supply, laundry, tailoring, compound and ward cleaning, waste disposal and waste water treatment. The domestic services of the Guest House and the Teaching Centre are as well available for workshops and seminars. They generate some income so much needed to cover the running costs of the Hospital. The Hospital provides beddings (bed sheets and blankets) and uniforms to its patients made by the tailoring department. All the washing of Hospital linen is done by the laundry department. This helps to ensure good patients hygiene and infection control. The compound is maintained by a team of compound workers. They are also responsible for proper waste disposal into rubbish pits, placenta pits or incinerator. Cleaning of wards is by the Hospital cleaners. Waste water treatment is done using a biological waste water treatment system. The clear water produced at the end of the biological process is used to water plants in different Hospital gardens especially during the dry season.

C) General Store and distribution of food

The General Store was under the supervision and motherly care of a missionary sister who died on the 7th April 2018. She is dearly missed by the four support staff members who are now supervised by the PNO. A tribute to + Sr. Giovanna Ruaro is in the Annex.

75 of 108 Also during FY 2017/18, in collaboration with Insieme Si Può (ISP) the Hospital has been providing nutritional support to extremely vulnerable patients. The types of food supplied and quantities are tabulated below. However food supplies are reducing as the support has decreased. Special feeding programmes are in place for malnourished children in the Inpatient Therapeutic Centre (supported by UNICEF, through supply of formula feeds) and TB inpatients (supported by IDEA, Turin).

Table 7.1: Food distributed in FY 2014/15 - FY 2017/18

Food Amount Amount Amount Amount distributed during distributed during distributed during distributed during specification FY 2014/15 (kg) FY 2015/16 (kg) FY 2016/17 (kg) FY 2017/18 (kg) Beans 14,400 12,500 9,100 9,200 Rice 4,318 5,179 6,630 6,100 Maize 19,450 16,550 14,400 8,600 Vegetable Oil 2,386 1,961 1,976 2,104 Sugar 4,456 4,448 4,536 5,075 Dry Milk 1,611 1,366 1,581 1,420

D) Ambulance Service

The Hospital offers ambulance services within the catchment area and occasionally referrals to Mbale or Kampala. There is a call line for this service. The road situation to reach the Health Centres in the catchment area (Bokora Health Sub-District) in the rainy season is causing delays, as longer routes have to be used and high cost of maintenance to the vehicles. Two Toyota Landcruiser Ambulances (procured 2003 and 2010) are regularly serviced by the mechanic section of the Technical Department and are kept most of the time in working condition, though the acquisition of spare parts is becoming ever more difficult. The arrival of the new Ambulance in September 2017 has improved the rescue of patients greatly, especially referrals to distant places. The cost of each trip varies. As a baseline 1,500/= UGX per km are calculated for fuel, wear and tear and driver’s allowance. Through Moroto Diocese the Hospital received from a Karamoja Support Group from Trento (Italy) a VW T5 Ambulance the other year. This Ambulance will mostly used for referrals to Mbale or Kampala and once the road Moroto - Soroti is tarmacked also along this route. The Hospital has maintained free ambulance services with CUAMM support for neonates and obstetric emergencies as an affirmative action to promote maternal and child health. A midwife is now part of the emergency team that goes to pick obstetric emergencies from health centres. Also a subsidised ambulance service is provided to transport the deceased from the Hospital to their homes within the catchment area. Other Hospital vehicles are one Toyota Landcruiser for the PHC Department to carry out support supervision and integrated programmes. A four wheel drive Hospital lorry to ferry Hospital supplies, drugs, surgical sundries, building materials, food, etc. mainly from Kampala (470 km one way). Two Benz 911 lorries of which one has a crane and a tractor with two trailers are available for the Technical Department.

E) Technical services – The Technical Department

The Technical Department with a total of 40 established employees is a guarantee that maintenance and renovation works are done daily in the Hospital. New building projects within the Hospital are carried out by and only by this workforce as quality work is guaranteed. It is supervised by a Comboni Lay Missionary. The following cadres are present: mechanics and drivers, electricians, plumbers, metal workers, builders, carpenters,

76 of 108 and store keeper. There are also some workers in the tree nursery for the tree plantation project of the Hospital. Besides the ordinary routine maintenance and repair of equipment and buildings, the works carried out in 2017/18 were: Completion of major renovation of St. Bakhita Hostel of the Nursing and Midwifery Training School, as well as of an underground rainwater tank. The renovation of the NMTS Library will be carried out in FY 2018/19, as the funds from OPM finally reached the Hospital. The building of a new staff house for six units has been completed. The patients' kitchen has been well accepted. A new Ambulance was received in September 2018 and is well in use. The overhauling of the water piping system in the Hospital with installation of two new water tanks each 50,000 litres was almost completed. The installation of a fire fighting system in the Hospital with water hydrants at strategic points us well under way and almost complete. The Renovation of old Patient Attendants Kitchen which was turned into an Archive and IT-Store has as well be completed. Major renovation was done to the TB ward patients’ bathrooms and toilets. After a long time also the Technical Department was renovated as last intervention supervised by the former In Charge and Lay Missionary Peter Gruska. Various services to the public as income generating activity by this department to supplement the running costs of the Hospital prove the importance of this department. The water supply to the Hospital has been constant during the course of the FY. Water is provided by two bore-holes (one about 1,500 m West of the Hospital), with one submersible pump linked to the Hospital generator by an underground cable, and another within the Hospital compound, operated as well by a submersible pump. For patients and their attendants there is a bore-hole with hand pump in the Hospital compound. A biological waste water treatment plant provides clean water for watering plants in the compound and a fruit tree plantation. Two underground water reservoirs for rain-water collected from the entire hospital roofs, supplies water to the laundry, thus reducing the water consumption from the boreholes. In September 2016 a greenhouse was purchased and put up with drip irrigation. Surrounding vegetable beds were also created and its produce utilised for the NMTS and the staff. The purchase of a second greenhouse will be possible within this FY 2018/19 through the support of a children's group. In connection with this project a small dairy goat project with six goats was started in May 2018. Electricity is produced by generators and an extensive photovoltaic plant. The Hospital was connected to the National Electricity Grid in November 2015. Its availability has improved but there are still times when the grid is off.

 Recommendations

The weather condition in Uganda due to global warming has greatly changed in the past few years. The quality of the roads especially during rainy season is poor, which results in higher fuel and maintenance cost of vehicles. Demand of oil products in the world have risen sharply as well which has direct impact on the cost of service delivery of the transport division (ambulance and transport of goods).

F) PASTORAL CARE

The spiritual support of the patients is of vital importance to give a holistic approach to healing. Pastoral care of the sick people is one of the essential care package provided to our patients. A long serving Pastoral Care Giver together with a young charismatic man who attended a ten week Clinical Pastoral Education Unit organised by UCMB in July/August 2016 and a support staff who has been showing availability to pray and accompany the sick are involved in the pastoral care of the patients. In February 2018 two Junior Sisters of the MSMMC joined the Team in part time. They are all closely supported by the Parish Priest.

77 of 108 Holy Mass is celebrated in the Hospital Chapel with participation of staff, students, attendants and patients every Thursday and on special occasions, like the World Day of the Sick, etc.. Recollections are organised for staff and students during Advent and Lenten season. The NMTS church choir routinely animates during Sunday mass at the Parish. The Hospital also supports parish pastoral work through actively participating in Parish activities like organising special celebrations at the parish, provision of transport, tents and monetary support.

Table 7.2: Trend of activities in Clinical Pastoral Care of the Sick

FY FY FY FY FY Activity / Indicator 2013/14 2014/15 2015/16 2016/17 2017/18

No. of patients visited or counselled 8,025 9,431 17,998 27,426 28,452

No. of patients baptized 3 12 18 12 12

No. of patients confirmed 0 0 0 0 0 No. of patients given Sacrament of 0 0 1 1 0 marriage No. of patients anointed 18 34 42 25 24

No. of patients for Holy Communion n/a n/a 71 129 85

78 of 108 CHAPTER EIGHT

QUALITY AND PATIENT SAFETY IMPROVEMENT

The Hospital strives to continue offering quality care to patients in a safe environment. The Hospital has a quality assurance and quality improvement team which periodically assesses quality of care provided to patients. Some of the quality improvement activities done include; spot quality checks on wards, training of staff on quality assurance, procurement of required sundries, conducting patient satisfaction and drug prescription surveys etc. Feedback on these surveys was given in a general staff medical education meeting. Recommendations and suggestions were made for improvement and implementation. Assessment of the various wards following the 5 S’s entailed in quality assurance was also done which has resulted in general improvement of service delivery in the wards.

1. QUALITY IMPROVEMENT ACTIVITIES UNDERTAKEN

The table below shows the quality improvement activities which were carried out and the subsequently effects realised

Activity Effect Introduction of a midwife as part of the Improved care during obstetric emergencies ambulance team to pick mothers in labour from peripheral health units. Added a second cashier for in-patients (on Reduction of waiting time for discharged wards) patients to pay Hospital bills Trained 2 quality control officers from each Improved quality of care given to patients department. Carried out patient satisfaction and drug Improved client satisfaction of services prescription surveys for 2018 provided and drug prescription practices Enrolment of the Hospital laboratory in the Reliable laboratory service through having SLMTA program and attained star two accurate and timely test results. Conducted health education on wards Better patient understating of various involving students and staff. Each ward has health issues a schedule of topics to be discussed. Held regular meetings of the maternal and Improved maternal and perinatal care. perinatal death review committee Held daily nursing and clinical audit Improved nursing and medical care of meetings. patients. Recruitment of more staff in the pastoral increased access to pastoral care services care department Attendance of several trainings by staff Increased knowledge and skills of staff during the year. Started the alcoholics’ anonymous group Improved care for alcoholics for alcoholics Started a paediatric diabetic clinic to Better care for children with diabetes provide specialised care for children with diabetes Commemorated the world day of the sick. Improved social and psychological Hospital community, patients and wellbeing of patients attendants actively participated.

79 of 108 2. QUALITY INDICATORS

A. Technical competence and effectiveness of care

Table 8.1: Proxy Indicators measuring the effectiveness of care in the Hospital

2013/14 2014/15 2015/16 2016/17 2017/18 Explanation Recovery rates on discharge:

Recovery patients in one year discharged 95.2 95.2 98.6 99.6% 97.1% as clinically recovered from that Rate episode of disease (from all wards) following treatment. Maternal death rates: is not a 2.17% Maternal population based maternal 0.34% 0.1% 0.17% 0.08% death rate mortality rate or ratio that you 0.66 may often comes across. Fresh still 1.98% Fresh still birth rate: Fresh Still 0.17% 0.3% 0.2% 0.16% births have intact smooth skin births rate 1.32% not macerated. Early neo-natal deaths rate. Number of babies who died Early within the 7th day from birth Neonatal 1.42% 3.87% 3.58% 2.41% 2.88% divided by the total number of death rate deliveries in the hospital in that year expressed in percentage terms. *highlighted are the rates including Hepatitis E cases

Recovery Rate

Our recovery rate reduced but remained within acceptable standards if we consider the severity of medical cases reaching the Hospital.

Maternal deaths

During FY 2017/18, two maternal deaths occurred in the Hospital, giving maternal death rate of 0.16%. One death was of a mother referred from Kapenguria - Kenya through Amudat Hospital with severe septicaemia following post abortal sepsis, the second was referred from Nakapiripirit District due to puerperal sepsis with a brain abscess. Maternal death audits were done as per the Ministry of Health recommendation using the standard guidelines. Each of the events was reported to the District Health Office and Ministry of Health HMIS data

Fresh still births The fresh still birth rate was 0.2%. Hospital had two fresh still births. These were babies born dead but known to be alive at the time of arrival at the Hospital. Efforts have been made by the Hospital to keep the fresh still birth rate as low as possible

Early neonatal deaths Early neonatal deaths increased from 2.41% to 2.88%. The Hospital had 37 ENND in FY 2017/18. Major causes of death were prematurity, birth asphyxia and neonatal septicaemia. Management protocols for sick neonates have been updated to improve care. Perinatal death audits have been done and monthly reports sent to Ministry of health. Kangaroo mother care is being practiced. Neonatal referrals from lower level health units were also difficult to manage as they were referred late already with severe infection. Presence of new borne resuscitation equipment at LLHUs and education of the Midwives will greatly improve wellbeing of the new born.

80 of 108 B. Safety of Intervention

The chosen indicator for measuring safety of intervention is Caesarean section infection rate.

Table 8.2 shows trend of C/S Infection rates over the last 5 years

2013/14 2014/15 2015/16 2016/17 2017/18 Explanation C/S infection c/s infection rate 0% 0% 0% 0% 0% Number of post-operative rate mothers who get infections

There were no cases of post caesarean section infections at time of discharge from Hospital reported during the FY out of the 376 caesarean sections performed. The World Health Organization stipulates that this parameter of quality should be less than 10% in any health facility that provides emergency obstetric care services. Based on this yard stick, Matany Hospital performance continues to be excellent.

C. Availability of Qualified Staff

Table 8.3: Proportion of clinically qualified staff in the Hospital

FY FY FY FY FY Indicators 2013/14 2014/15 2015/16 2016/17 2017/18 1 Total staff 248 208 221 233 249 2 Qualified staff 128 120 126 137 152

3 Proportions of qualified staff 51.6% 57.7% 55.01% 58.8% 61%

There has been a progressive increase in the availability of qualified health workers in the Hospital over the last years. The Hospital Management Team made it a priority to improve the staffing norms in various departments in the Hospital. The other major contributor to this achievement has been a significant reduction of staff attrition. The majority of our staff faithfully served their contracts or bonding agreements to completion, and some of them even opted to renew/extend their contracts. The proportion of qualified staff is now 61 %, therefore the aim to have at least 45% of qualified staff in the Hospital has been achieved by far. Seven staff upgraded and attained diplomas during the year. They are bonded and working in the Hospital.

Graph 8.1

%age of qualified Staff 70%

58.8% 61% 60% 52% 57.7% 57% 50%

40%

30% 2013/14 2014/15 2015/16 2016/2017 2017/2018

D. Patient Satisfaction

This survey addresses the Clinical outcome as perceived by the patient with regard to clinical effectiveness, namely: improvement, loss of pain, humanity of care (i.e. staff

81 of 108 attitude and patient involvement in care), organisation of care in terms of flow of clients and waiting time before seeing clinician, healthcare environment (e.g. toilet facilities, beddings and bathrooms). Also assessed is overall impression, whether patient is satisfied and willing to come back. Humanity of care remained high at 100% indicating that our staff were kind. Patient involvement in care increased by 2.9% from 96.2% to 99.1%. Cleanliness of Hospital environment was rated 100%. Regarding the Total Patient Satisfaction Rate, Matany Hospital scored 92.1% in 2018 compared to 97% in 2017.

Table 8.4: Patient satisfaction levels per core areas

Satisfaction Satisfaction Satisfaction Criteria commented Comment rate 2015/16 rate 2016/17 rate 2017/18 Clinical outcomes It is a good development if (Improvement after 96.1 93.8 94.2 patients feel that they have care) improved after care received Humanity of care 99.6 100 100 (Kindness) staff were kind Patient involvement in Need to continue involving 96.5 96.2 99.1 care patients in their care The healthcare Patients appreciate the general 100 99.1 100 environment cleanliness in the Hospital Waiting time (less than 94.7 96.9 85.8 Waiting time increased one hour)

E. Medication safety

Drug prescription is one of the quality indicators of clinical care provided by the Hospital. Consideration is given to appropriate prescription (poly pharmacy, antibiotic rate, injection rate), dispensed drugs in relation to prescribed drugs (added up to the scores for appropriate prescription). According to WHO standards, average number of drugs prescribed < 2.6, antibiotics as a percentage of total drugs prescribed < 20% (Uganda <40%), Injections should be <15% of drugs prescribed. All (100%) prescriptions should have history and objective examination recorded, and all prescribed drugs actually dispensed. Since FY 2003/04 a regular monitoring system was re-vitalized in order to get information on prescription practises in OPD among Medical Officers and Clinical Officers. This has served a great purpose to regulate poly-pharmacy, in order not to deviate from the WHO/MoH standard recommendations. The polypharmacy rate in 2017/18 was 1.9 which was an improvement compared to last year of 2.05. It remained below the WHO recommendation of 2.6 The injection rate increased from 0.6% in 2016/17 to 5.3% in FY 2017/18. However injections were indicated for all the patients who received them. All patients received the prescribed drugs giving a dispensing rate of 100%. This indicates good drug stocking levels.

The percentage of outpatients getting an antibiotic in a prescription was 24.5% which was an increase compared to 13.4% of 2016/17. Antibiotics were given mainly for respiratory and pelvic inflammatory diseases. Constant use of the Uganda clinical guidelines will help to control antibiotics use. Monthly prescription trend for antibiotics and Non Steroid Anti Inflammatory Drugs (NSAIDS) are indicated in graphics 8.2 and 8.3, respectively.

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Graphic 8.2 Prescription of Antibiotic in OPD during FY 2017/18

Matany Hospital OPD: % of prescriptions with antibioticduring FY 2017/18 50.0 37.1 34.0 33.7 36.7 40.0 34.0 38.6 30.4 31.4 30.0 37.2 29.9 25.2 28.5 20.0 WHO recommends <20% 10.0 ( MoH-Ug recommends <40%) 0.0 Jul- Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 17 18 18

Graphic 8.3 Prescription of NSAID in OPD during FY 2016/17

Percentage of antinflammatory drugs prescribed to OPD patients during FY 2017/18 50.0%

40.0%

30.0%

20.0% 11.2% 13.9% 10.4% 9.5% 10.8% 10.0% 9.1% 11.4% 8.7% 9.3% 8.3% 9.0% 7.3% 0.0% Jul- Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 17 18 18

The number of NSAIDs prescribed reduced during the previous year. They were used as pain killers. All the drugs prescribed were available in OPD pharmacy during the year under review. Free malaria drugs were received, thanks to the regular information from JMS on availability. The Hospital now orders some drugs like TB drugs directly to NMS which helps to prevent stock outs.

Graphic 8.4 Average numbers of Diagnoses made for a patient in OPD during FY 2017/18

Average number of diagnoses per OPD patient during the FY 2017/18

1.8 1.5 1.2 1.2 1.2 1.1 1.2 1.2 1.2 1.1 1.2 1.0 1.0 1.0 1.0 0.9 National Standard 0.6 Figure < 1.5% 0.3 Jul- Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 17 18 18

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Table 8.5: Summary of Quality rates per indicator

Years FSB MDR RR IRCS STAFF SATIS DRUGS rate rate rate rate rate rate rate 2011/12 1.46 0.46 96.9 0.37 48 16 90 2012/13 1.64 0.4 96.2 0 49 100 96.5 1.98* 2.2* 2013/14 95.2 0 52 96 96.5 1.32 0.6 2014/15 0.17 0.34 95.2 0 57.7 96.3 100 2015/16 0.27 0.11 98.6 0 57.01 96.3 100 2016/17 0.2 0.1 99.6 0 58.8 97 100 2017/18 0.16 0.08 97.8 0 61 92.1 100

* with HEV impact

Performance Indicators

Matany Hospital is a major contributor to the health care outputs in Karamoja region and neighbouring Teso. Annually, the Hospital performance is assessed on core hospital functions; quality of care and efficiency of resource utilization. Hospital performance can be measured through some indicators developed by Uganda Catholic Medical Bureau (UCMB). These indicators can be used to rank different hospitals on basis of their out puts; and to monitor the performance of the same hospital over subsequent years.

Matany Hospital provides several health services to the people and these services can be seen as outputs. The main outputs of a hospital include; the number of patients seen in OPD and special clinics, admitted in the wards, the number of mothers who attended Antenatal Care, Immunizations done and Deliveries conducted throughout the period under review.

Giving a weight to each of the above outputs, five outputs are measured against a term of reference (Op = 1 outpatient contact), UCMB has produced an aggregated indicator of outputs called Standard Unit of Output (SUO-OP). SUO-OP is calculated using the following formula:

SUO-OP = ( 15 x no. IP) + ( no. OP) + (5 x no. deliveries) + (0,2 x no. of immunizations given) + ( 0,5 x ANC visits)

In a similar way SUO-IP Standard Unit of Output per Inpatient) can be calculated. Starting from SUO-OP/IP and knowing the total expenditure of the Hospital, the income from patients user fees, the number of qualified staff, the bed capacity, the workload of OPD, PHC Department and wards, it is then possible to calculate other indicators called SUO-OP per staff (productivity of staff), cost per SUO-OP, cost per SUO-IP, median user fees per SUO-OP, median user fees per SUO-IP. These indicators can be used to measure the accessibility, the equity, the efficiency and the quality of Matany Hospital.

Hospital accessibility is measured looking at its utilization and therefore SUO-OP is the best indicator. During 2017/18 the SUO-OP showed a slight increase as compared to the previous FY (see Graph 8.5). This is explained by the fact that there was some increase of the number of outpatients, inpatients and deliveries.

84 of 108 Graph 8.5: SUO-OP as measure of accessibility

Trend of general performance using SUO 280,000 252,944 256,486 245,000 214,994 212,209 210,000 211,870

175,000 Total SUO SUO Total

140,000 2013/14 2014/15 2015/16 2016/17 2017/18

Another useful indicator of accessibility is the Cost Recovery rate from user fees (CRR) that is the percentage of expenditures (recurrent cost) covered with money coming from user fees: in Matany Hospital for the FY 2017/18 this was 19.25%. According to UCMB the accessibility is good when this value ranges between 25-30%. Our CRR is still below average for the UCMB Health Network; this is an indicator of good service access and equity to the rural poor. This task of providing one of the most subsidised health services in the country is becoming more difficult in the present circumstances where resource mobilisation is an up-hill task for the Hospital Management Team.

Measuring equity: a hospital is equitable when people who are really in need, i.e. vulnerable groups: children, pregnant women, are served more and more. Three indicators are used: median user fees per SUO-OP, utilization of services by pregnant women and immunizations given to the population. Graph 8.6 indicates median user fee per SUO-OP and SUO-IP in the previous five years while no. of immunizations given and Antenatal Care Clinic workload are discussed in Chapter 6. The graphic indicates that there was an increase both in the Median User fee per SUO-OP and SUO-IP. However Matany Hospital median fees per SUO remain among the lowest in the UCMB network hospitals in Uganda. It is important to note that no patient is turned away from accessing services; the Hospital has a Samaritan Fund which is used to care for those patients who are identified as not being in position to meet the cost of user fees.

Graph 8.6: Median user fee per SUO-OP and SUO-IP over the last 5 years

Matany Hospital Median User Fee per SUO-OP and SUO-IP since FY 2013/14

40,000

26,241 26,168 30,879 30,000 19,216 20,000 15,429 UCMB Ø 11,119 UGX FY 2017/18 10,000 1,018 1,267 1,731 1,729 2,039 0 FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18

M edian User fee per SUO-OP M edian User fee per SUO-IP

85 of 108 Considering no. of qualified staff and total cost of the Hospital, two other indicators, measuring the efficiency, SUO-OP per staff (productivity or technical efficiency) and Cost per SUO-OP (economic efficiency) can be calculated.

Graph 8.7 below, indicates the SUO-OP per staff and cost per SUO-IP. The graphic reveals that the SUO-OP per staff (productivity) has decreased from 1,846 (for the previous) year to 1,687 (this year). This is an indicator that more staff attended to patients who were seen in OPD and admitted in the Hospital.

Cost per SUO-IP increased which was expected and reached the level of two years before. In conclusion, our staffs were a less productive as compared to the previous year because more staff were employed but the number of inpatients did not increase the same level, although there was a slight increase of workload.

Still, all these indicators do not take in consideration the quality of service as a single patient might have e.g. to be taken to theatre for surgical toilet, etc. several times thus consuming working time for our staff and resources but still counted to be just one patient. It has also to be mentioned that such indicators do not reflect the severity of the conditions of admitted patients.

Graph 8.7: SUO-op per staff, Cost per SUO-OP and SUO-IP (technical efficiency indicators)

Matany Hospital Cost per SUO-op and SUO-ip since FY 2013/14 250,000 194,910 183,382 188,681 186,870 200,000 166,505 150,000

100,000

50,000 12,864 12,446 12,093 10,998 1,687 0 1,658 1,792 1,682 1,846 12,973 FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 FY 2017/18

SUO-op per staff Cost per SUO-op Cost per SUO-ip

86 of 108 CHAPTER NINE

HEALTH TRAINING INSTITUTION

St. Kizito Hospital - Matany School of Nursing and Midwifery is a full Board Vocational training School, located in Matany Sub-county, Napak District, Karamoja Sub – region. It was established in October 1984 and begun with Certificate in Nursing with a vision for quality training of health care Staff of high moral and professional standards. In May 1993 introduction of extension in registered nurse training course was implemented; which later was suspended in May 2010 with the introduction of Certificate in Midwifery training.

The school capacity was determined at 90 students due to the available space both for accommodation and classrooms, and availability of qualified tutors as guiding indicators. Due to demand for midwives in the region, the capacity has increased to 115 students. However, the school with other development partners including Government strive to increase gradually the school’s capacity from 90 to 120, thus aiming at an increase of 30%. This depends on the staff development over the years, and other capital development plans to be realised.

The school is managed by the Hospital Management Team including the Principal Tutor, as one of the main departments of St. Kizito Hospital Matany which is fully owned by the board of Trustees of Moroto Catholic Diocese. The HTI has a Statutory Committee of the BoG which handles the school issues.

The types of courses at the school:

Table 9.1: Types of courses

Number of Number of Number of Number of No of No of students Success Course Students Students Students Students Total students sat passed final rate New Intake 1STYear 2ND Year 3RD Year final exams exams CN 25 00 19 14 58 14 14 100%

CM 23 00 22 12 57 12 12 100%

TOTAL 48 00 41 26 115 26 26 100%

This FY 2017/2018 the Students Population was: 115

Student numbers as per gender:

CN May 2015 = 14 (Female: 09, Male 05) CN May 2016 = 19 (Female: 12, Male 07) CN Nov. 2017 = 25 (Female: 15, Male 10) CM May 2015 = 12 (Female) CM May 2016 = 22 (Female) CM Nov. 2017 = 23 (Female)

87 of 108 ACADEMIC PERFORMANCE

Student success rates according to grades

Graph 9.1: Showing certificate in nursing and midwifery students’ performance in grades

Looking at the above grading pattern according to the various intakes, there is improvement in the academic performance and practical skills as the grading changes from credits and few distinctions to Credits and Passes. There is need to maintain and improve for better performance. Students who obtained credits were more in FY 2014/2015 compared to the last five years. In FY 2016/2017; there was 01 Distinction, 28 Credits, 01 Pass, 01 failure and FY 2017/2018 had 25 Credits with 01 Pass.

Success Rate for the Financial Year 2017/2018: Table 9.2: Success rate for CN/CM 2015 May Intake in the FY 2017/2018

N° of Students who sat N° of Students who passed Success Rate UNMEB Final Exams UNMEB Final Examinations Course Non-ref. Ref. Failure Pass Credit Distinction Percentage CN 14 0 00 00 14 00 100% CM 12 0 00 01 11 00 100% TOTAL 26 0 00 01 25 00 100%

In November 2017 twenty six CN/CM 2015 May intake Candidates sat for UNMEB State Final examinations; the fourteen CN all performed well and obtained Credits.

Table 9.3: showing the success rate in the last five years

Course - CN/CM 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 New admissions 35 33 33 00 48 Lost during the year 03 01 03 05 03 Referred during the year 03 00 03 07 00 Success Rate 100% 100% 100% 97% 100% Fail at 1st attempt 00 00 00 01 00 Fail 2nd attempt 00 00 00 00 00

88 of 108 In November 2017 twenty six CN/CM 2015 May intake Candidates sat for UNMEB State Final examinations; the fourteen CN all performed well and obtained Credits. The twelve CM were the sixth group of Midwifery students since the inception of the program in the HTI. They performed fairly well with the following grades 11Credits and 01 Pass. The seventh and eight sets are continuing well with the course. This FY 2017/2018, the HTI management identified the following key priority areas as vital, and therefore all activities within the year were geared towards fulfilment of these priorities. 1. Sustainability of the quality of training 2. Strengthen the clinical area supervision 3. Maintenance of HTI physical infrastructure and to reduce costs 4. Strengthen counselling and guidance of students 5. Improve the use of ICT

Sustainability of the quality of training:

During the previous year the tutor-student ratio was 1:36, the students are taught theory and practical skills. The hospital management has reinforced the teaching staff with two Diploma nurses to teach in the school, two Clinical Instructors and eight Preceptors who have contributed a lot in training of the students besides the three qualified Tutors and the current tutor-student ratio has slightly increased to 1:38.

The Hospital Management Team and HTI Team planned to carry out the following activities: Identifying staff for tutor training: There is still need to identify more staff for tutor training particularly for Midwifery courses. The identification of capable Staff to be trained in the areas of Clinical Mentors is on-going; coupled with career guidance so that with time the staff will go for upgrading courses and become tutors. Some Staff had been identified for upgrading, for diploma in Nursing and Diploma in Midwifery; this will beef the sustainability of quality training in the HTI as well as the clinical site in the hospital. Practical experience through field attachment: Moroto Regional Referral Hospital and Kangole HC III has been chosen for practical experience and field attachment. Memorandum of Understanding has been signed between the HTI and the relevant authorities of these facilities. Annually the third year students had been placed for a period of one month and two weeks in these facilities for practical experience. Short courses: On-line course in Health Services Management has been organized for fifteen Mentors of the students. Two Clinical Instructors from the HTI and thirteen Clinical Mentors from the clinical site in the hospital. One Tutor and a Clinical Instructor attended in-service training of five days on Nutrition. This was very useful since it enabled acquisition of updated skills for efficient service delivery at the HTI and Practicum site. With time other refresher courses shall be organised for both teaching and administrative staff in order to build their capacity.

Strengthen the Clinical Area supervision:

This is in order for the students to perform better at the practical sites, and have their practical skills improved for quality and safe care of the patients. It is also coupled with the needs to produce future Nurses and Midwives with highly professional and technical standards that can meet the present health demands of Karamoja region, Uganda and other

89 of 108 nations respectively. Therefore the HTI Management sought the need to achieve the above priority area by undertaking the following actions:  The HTI shall continue to identify and mentor more student nurses and midwives who are capable of instructing and taking up the clinical instruction activity after their qualification.  Orientation and induction courses for the mentors identified.  Regular meetings between the HTI and Staff at Practicum site to monitor and evaluate students’ performance.  Involving actively the Preceptors and departmental leadership at the practicum site in training and supervising students when in the clinical area (on-going).  Regular Clinical Teaching sessions in all the wards for better assessment of hands on skills (on-going).  Recruitment/training of more tutors in order to re-instate the diploma programme that had been suspended.

Reflecting on the numbers of referred students and those who left the training in the last three financial years; the detailed information has been described at table 9.4.

Table 9.4: Number of lost and referred students in the last five financial years

Course CN & CM 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 Lost during the year 03 01 03 05 03 Referred during the year 03 00 03 07 00

The loss of students during the last four Financial Years was attributed to gross breaches of HTI rules and regulations many of which involved ethical, professional, and moral issues. This resulted in a number of HTI Welfare/Disciplinary meetings and decisions that were painful for the students, their families and the School management.

FY 2017/2018 had no students referred to another class this has been attributed to good academic performance and the three students were lost during the year; one was due to forged S. 4 documents discovered during verification exercise by the MoES, the other had pregnancy and the third had persistently unethical behaviour in spite regular Counselling and Career Guidance attempts offered to help her concentrate in the training she had embraced. To achieve the above the teaching Staff continues to do the following:  Detailed teaching of Nursing Ethics and moral standards of the profession to the incoming students and revision with the continuing students.  Invite various external opinion leaders to give Career Guidance to the students.  Use of collective efforts by the HTI and Clinical Teams to remind students about professional standards and strengthen their ethical codes of conduct both in class and clinical area.  Guidance and counselling of students by Tutor referees for each class, promotion and strengthening of guild leadership has contributed a great deal in creating a friendly environment of learning in the HTI.  Involvement of family members/guardians in solving students problems

Maintenance of HTI physical Infrastructure:

Renovation of the existing school buildings in stages has started although it has been temporarily suspended due to an urgent need of the water system haulage in the entire school and the hospital premises. Gadgets have been put in place to monitor electricity and water so that wastage is minimised; the on-going maintenance of these equipment has been

90 of 108 well catered for by the technical department of the mother hospital. Students are reminded continuously about care of all the properties. The school rules and regulations were revised and await the approval of the BoG. The HTI has to continue lobbying for more funds from development partners for the sustenance of the infrastructures in place and create a conducive environment for learning.

Strengthen counselling and guidance of students:

This is on-going by the tutors. From time to time some facilitators were invited to give inputs which promote good moral behaviours and spirituality. Students were encouraged to actively and regularly participate in spiritual activities, associations such Young Christian Student (YCS), Christian Young Missionary Group (CYMG), Legion of Mary and St. Peter the Apostle Society (SPA). Regular recollection days were organised for their spiritual growth and educative films shown to broaden their knowledge and critical thinking.

Improve the use of ICT

The Computer Laboratory has been set in place and plans are underway to purchase more computers to enable each student easy access for practice and acquisition of computer skills. The Computer literacy that has been introduced is on-going; the students are examined on this subject and the marks are included in their academic school transcripts. Teaching students using Power point presentations and group discussions is in progress since these are some of the teaching methodologies encouraged for better understanding. Table 9.5: Indicators of faithfulness to the mission:

Faithfulness to Mission 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018 Indicator ACCESS (utilization rate) 100% 100% 100% 100% 100% EQUITY (fee per student) 1,477,132 1,275,528 1,532,125 1,662,384 1,990,705

EFFICIENCY (expenditure per student) 1,697,228 1,696,639 1,742,716 1,770,954 2,120,599 QUALITY (success rate) 100% 100% 100% 97% 100% QUALITY (Tutor/Student ratio) 1:38 1:36 1:36 1:36 1:38

The above table shows the HTI’s faithfulness to the mission in relation to the four key indicators compared to the last five financial years.

Access: An indicator that looks at the capacity of the school and determines its usage. The number of students has increased because of two concurrently running programs and introduction of semester system enrolment of the students to fit the semester examinations. The number has gone beyond the targeted capacity of 90 students to 115. There has been extra beds fitted in the hostels; this explains the 100% utilization rate.

Equity: This looks at the average fee per student. Due to the rising costs of living, the fee has slightly increased compared to the two previous Financial Years. In spite this slight increment, students are on-going with their training and no drop out due to lack of tuition fee has been registered thus the HTI has been more equitable.

Efficiency: This looks at the average recurrent cost per student. The Hospital continues to support the school in feeding, supplies and maintenance, through bulk purchases and storage of food stuff and other items which are usually a bigger component in students’ cost. It is noted that expenditure per student has slightly increased this could be attributed to the general rise of prices.

91 of 108 Quality (students’ success rate): This has been 100% in the previous five financial years; apart from FY 2016/2017 the success rate has been 97%.

Equality (Qualified Tutor-Student ratio): This ratio stands at 1:38 as the tutors are now three in number. Quality has improved because of the increase in the number of the tutors, Clinical Instructors and Preceptors at the Clinical area.

In the FY 2017/2018 the HTI Team with the HTI Statutory Committee managed to balance the number of staff at the school with those that left for further training. Currently, the HTI staff statistics stands as presented in the table below.

The evolution of the Staff establishment in the HTI:

Table 9.6: Staff establishment statistics in the last five Financial Years:

Staff Categories 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018

Qualified Tutors 3 3 3 3 3 Qualified Clinical Instructors / 0 0 0 0 0 Mentor Unqualified Clinical Instructors 2 3 2 3 4 N° qualified teaching Staff lost in 0 1 0 0 0 the year Attrition rate qualified teaching Staff 0 1 0 0 0 N° qualified teaching Staff 0 0 0 0 2 recruited during the year N° unqualified teaching Staff 0 1 1 0 1 employed during the year N° unqualified teaching Staff lost 1 0 1 0 0 during the year Attrition rate unqualified teaching 1 0 1 0 0 Staff Support Staff 10 10 12 11 11 N° of Hospital Staff Members 3 0 1 1 1 providing lectures in HTI Ratio part-time versus full-time 3:3 2:3 1:3 1:3 1:3 qualified Tutors

The number of the three tutors has contributed greatly to the reduction of the high tutor – student ratio from 1:38 to 1:36; at the same time Tutor-Student Ratio for the last three previous Financial Years remained stable. However with the commencement of semester system student enrolment in FY 2017/2018 the Tutor – Student Ratio went back to 1:38. It is our wish to continue identifying and mentoring more staff to be trained as Tutors in order to meet the recommended WHO Tutor – Student Ratio of 1:20 or UCMB Tutor – Student Ratio of 1:30. At the same time re-adjust the number of students per intake in order to meet the recommended standard of Tutor-Student Ratio.

Governance and Management of the School

St. Kizito Hospital Matany School of Nursing and Midwifery is governed and managed as one of the main departments and cost centre of the Mother Hospital. The title of the school management has been changed to Statutory Standing HTI Committee.

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In regard to the continuous management of the HTI, the Principal Tutor and entire teaching staff were involved in the following:

 Formulation and implementation of monthly clinical and class room teaching time tables. This entails class room teaching, progressive clinical and academic assessments, examinations, and organising/attending internal and external academic seminars, extra-curricular activities. All these activities are on-going.

 Discussing briefly main issues of the school on daily basis and weekly evaluation of the activities implemented. Having meetings scheduled fortnightly with teaching staff, supportive or administrative staff and quarterly meetings with In-charges of the wards and relevant departments of the Hospital to discuss professional, ethical training and moral issues. The minutes of these meetings are kept and read during subsequent meetings for better decision making, implementation, monitoring and evaluation. This is on-going.

 Conducting meetings with Guild Executive and the entire student body on regular basis to strengthen guild constitutional policies, remind students of HTI the importance of adherence to the school rules and regulations and to encourage leadership qualities among the student guild and generally to solve any arising problem in the school.

 Teaching staff participate in staff development programs such as training, attending seminars, technical workshops, and conferences. This is arranged as organised by the programme managers.

 Coordinating with the different stakeholders like Hospital Management Team, MoES/UNMEB, MoH/UNMC, Moroto Catholic Diocese, Napak District, Moroto Regional Referral Hospital and Lower Level Health Units as far as the school issues are concerned

School finances:

The budget of the school is approved together with the Hospital budget through the BoG. In the table below the different types of sources for the school income during FY 2017/2018 are shown.

Table 9.7: Source of income for the Health Training School

Income during Serial Source of income for the FY2017/2018 No. Health Training School UGX 1 Student Fees collection 179,872,500 2 Bursaries 58,400,000 Student Payment for other cost 3 19,431,100 (Registration/exams/specialised training.....) 4 PHC Conditional Grants to School 40,716,772 5 Other School Income (for services) 2,424,400 Total 300,844,772

The school being one of the departments of the Mother Hospital St. Kizito Hospital Matany gets management support for its finances from the Hospital finance department; this is done through timely update of the school management of its financial situation. The school accounts are audited as part of the Hospital account.

93 of 108

Income and Expenditure

The sources of income of the HTI are mainly school fees followed by bursaries and PHC Conditional Grant. Sustainability has improved over the years; the School administration in an effort to help talented students and will continue looking for bursaries from development partners.

Income

Graph 9.2: showing HTI Income in the FY 2017/2018

Sources of Income for the HTI, FY 2017/18

1% 6% 14%

19% 60%

School Fees Bursaries PHC CG Other Income For registration/exams/special training

Expenditure

Figure 9.3: Showing HTI Expenditure in the FY 2017/2018

HTI Expenditure in FY 2017/18

3.2% 5.3% 45.9%

34.0%

4.7% 6.8%

Employment Cost Admin. cost Utility & Property

Teaching Cost Transport Capital Devt.

Internally, the School receives unconditional administrative, financial support or in-kind for services from the mother Hospital. Much of its supplies are obtained from the Hospital main store besides purchases, transport and storage processes. All the repairs and building are done by the Hospital Technical Department. The Hospital takes care of 50% of students’ medical treatment bill and treatment of minor ailments of the HTI staff. The management of St. Kizito Hospital Matany takes care of Human Resource development of

94 of 108 the staff; at the same time it offers sponsorship to some of the needy students who are bonded to serve in either the Hospital or the Training School. The school receives support from the Local Governments of Napak and Moroto Districts through involvement in interviews and community activities. In Moroto Regional Referral Hospital the students during the period of placement, learn and get experience in Family Planning Clinical practice and other specialized care of patients. In Napak District, the students have field placement at the lower level Health Units, some selected villages for community diagnosis and in the Institutions of learning for school health programmes as well as participation in vaccination during child health days.

The HTI is continuously benefiting from the spiritual formation of the students offered by the Priests of Matany Catholic Parish, Faith-based organizations within and outside Moroto Diocese. It has also enjoyed a lot of support from the Diocesan Health Office, Diocesan Education Office and Diocesan Youth Office in both administrative and training activities.

Externally, the HTI is supported by the following partners in development:  UNFPA: - Sponsoring some Midwifery students of May 2014, 2015, 2016 and 2017 Intakes. At the same time equipment and text books for training and imparting skills to the students.  Straight Talk Foundations: - Sponsoring Nursing and Midwifery students May 2014, 2015, 2016, and 2017 Intakes  Government of Uganda: - Gives financial support through PHC – CG  OPM - Support for major renovations and sponsorship for some students  UCMB: - Offers administrative and technical support to the HTI by organizing workshops, trainings, meetings and technical advice during support supervision.  MoES-UNMEB: - Supports the HTI by organizing workshops, trainings, meetings, support supervision, verification of students’ documents, Promotional and State Final examinations.  MoH-UNMC: - Support supervision, verification of documents, Quality assurance and issuance of certificates, Professional ID and Practicing License.  Millennium Promise: - Sponsoring one Certificated Nurse May 2014, some of the Midwifery students of May 2016 and both Nurses and Midwives of November 2017 Intake.  Intrahealth: - Sponsoring Midwifery students of May 2014, 2015, and 2016 Intakes  Other partners and friends: Give services in kind, goods and donations

The HTI has been privileged to have the above partners who have faithfully continued to support its activities in training quality and highly competent professional Nurses and Midwives to serve this most underprivileged Sub-region of Karamoja, neighbouring districts, the entire country and other nations b) Other training activities of the Health Training Institutions(s):

Despite our limitation of under-staffing the HTI was able to carry out the following: Despite our limitation of under-staffing the HTI was able to carry out the following:

 Participation in some continuous professional medical education sessions organised by the Hospital on updated specific topics that are essential during the period of their training.

 HTI team planned and implemented Field attachment of students to Lower Level Health Units for four weeks and community diagnosis exposure activities. This is to

95 of 108 enable them understand the health needs of the people they are going to serve after completion of the training.

 Family Planning Clinical Practice in St. Kizito Hospital Matany and Moroto Regional Referral Hospital.

 Student involvement in both internal and external academic seminars.

 Admission ceremony and swearing in of the student guild committee members.

 Participation in extra-curricular activities like sports; music, dance, drama (MDD), and others

 Participation in November 2017 State Final UNMEB examinations and June 2018 End of Semester Examinations.

 Overall haulage of the water pipes and installation of two big water tanks for both hospital and the HTI has solved the crisis of water shortage in the two institutions.

Point of Action for FY 2018/2019

The achievements as compared to the annual plan are as follows:

In summary, the HTI was able to register great strides in the area of academic performance as was seen in the recent state final examinations results. However, the following could still place the HTI at a better position in future:  Training more Tutors and recruitment of more Clinical Instructors to meet the WHO recommendation of ideal standard, tutor-student ratio of 1:20 or UCMB recommended ratio of 1:30.  The HTI administration shall continue looking for avenues of acquiring some of the equipments that are still needed for the use of the students, such as computers, installation of e-Library, TV screen to enable them be in touch with the modern world.  Putting in place more strategies for resource mobilisation to complete the major renovation of the infrastructures and sustainability of the training school activities.  Frequent self-assessment exercise for the HTI team to improve in the management of the school.  Training more than one HTI team member in preparation of various HTI reports and strengthening clinical supervision of students.  Annually carrying out the student satisfaction survey of all finalist students.

96 of 108 CHAPTER TEN

SUMMARY, CONCLUSION AND RECOMMENDATION

Conclusion

Matany Hospital is the only Hospital in Napak District and it is well integrated in the community. The Public Health Department functions as Head of the HSD Bokora and collaborates with the District Health System. The Organisation and management of the Hospital is clearly described in Chapter three with the organisational structure. The Hospital relies heavily on external donations and its sustainability is therefore compromised. The infrastructure of the Hospital is well maintained facilitating quality care. It is renowned that the staff are well motivated and committed to the care of the patients which is serving as a model for future generation of nurses and midwives being trained in the annexed HTI.

1) Achievements and Failures

The Hospital achievements are spelt out in the Faithfulness to the mission report below, based on performance indicators. In general it was noticed that out patient attendance, admissions, deliveries, antenatal care and immunisations increased.

2) Faithfulness to the Mission report ( performance indicators)

Each year management prepares a report with performance indicators, demonstrating faithfulness to the Mission for which the Hospital was set as a health institution of the Roman Catholic Church. All the Hospitals under UCMB are reporting on these indicates which are: Accessibility, Equity, Efficiency and Quality.

 Is the Hospital more accessible especially to the vulnerable groups?

OPD attendance, admissions, deliveries, antenatal attendance and immunisation in the Hospital have increased compared to the previous year. Further the first line treatment of VHTs in the communities has helped patients at the onset of illnesses like malaria, cough and diarrhoea. It is noticed that private clinics and drug shops are on the rise within the District and it is not known whether qualified people are actually running them.

Table 10.1: Accessibility trend indicators over the past five years

Year 2013/2014 2014/2015 2015/16 2016/17 2017/18 OPD plus special clinics 57,866 78,175 63,015 87,603 89,658

OPD Attendance (new) 31,055 29,675 22,096 23,567 25,161 Admissions 9,290 9,556 8,665 9,903 9,927 Deliveries 1.060 1,164 1,118 1,161 1,283 Antenatal 5,006 4,859 6,395 3,526 3,890 Immunisation 35,950 41,733 50,462 46,141 47,815 TOTAL SUO 212,209 214,994 211,870 252,944 256,486

Table 10.1 above gives a comparative analysis of service utilization over a period of five years; OPD attendance (new) has increased by 1,594, and antenatal attendance increased by 364. The presence of VHTs working in the community gives a good impact. VHTs treat cough, diarrhoea and fever in the community which are the commonest illnesses seen in OPD. The community is mobile and more new settlements in hard to reach areas were

97 of 108 established. This possess a challenge to deliver health services to these communities. Admissions have increased by 24 as well as deliveries by 122. Total immunisations have increased by 1,674.

 Is the Hospital more equitable/affordable?

The trend of the user fee / SUO over the last 5 years as evidenced by the data in the report and shown in below graph 10.1, refers to the amount that a patient has to pay per hospital standard unit of output. If services are equitable, then the fee per SUO must remain low, so that even the poorest of the poor can afford. Equity for Matany Hospital had an increase of 415 from the previous year. The service provided by Matany Hospital remained equitable to last year in spite of its increase as the services continue being highly subsidised. In addition the Hospital continues to support the poor and destitute by treating them free of charge, debiting the Samaritan Fund.

Graph 10.1: Equity/Accessibility trend over the past five years

Trend of Equity over 5 years 3,000

2,500 2,144 1,729 2,000 1,731 1,267 1,500 1,018 1,000 500 Fees/SUO 0 2013/14 2014/15 2015/16 2016/17 2017/18

 Is the Hospital more efficient?

The SUO/staff (Staff productivity and the Cost (hospital expenditure/SUO) as evidenced by the data in the report show that Staff’s Productivity has decreased by 8.6 % (159) that is from 1,846 (for the previous year) to 1,687 (this year). This is because although the SUO slightly increased due to higher OPD attendances, admissions and deliveries, at the same time more qualified staff were employed. Hence the SUO/Staff has reduced as compared to last FY.

Graph 10.2: Trend of efficiency over the past five years

Trend of technical Efficiency over 5 years 2,000 1,846 1,800 1,792 1,658 1,687 1,600 1,682 1,400 SUO/Staff 1,200 1,000 2013/14 2014/15 2015/16 2016/17 2017/18

98 of 108  Is the Hospital offering care of better quality?

Quality care is measured by the trend of indicators like FSB rate, Recovery rate, Post C/S infection rate, MMR in the Hospital, % of staff who are qualified. These indicators were evidenced by the data in the report. Graph 10.3 followed by a table on the quality indexes are shown below.

Graph 10.3: Trend of quality indicators over the past five years

Quality indicators over the past 5 years 100 80 60 40 20 0 2013/14 2013/14 2014/15 2015/16 2016/17 2017/18 - HEV Recovery Rate Maternal deaths Fresh still births C-S inf. rate %age of qual. staff

2013/14 2013/14 2014/15 2015/16 2016/17 2017/18

Recovery Rate 95.2 95.2 95.2 97.1 99.6 97.1 23 Maternal deaths 7 4 2 3 2 HEV! 21 Fresh still births 14 2 3 3 2 HEV! C-S inf. Rate 0 0 0 0 0 0

%age of qual. staff 51.6 51.6 57.69 57.01 59 61

Special comments on Maternal Deaths and Fresh Still Births

During FY 2013/14, 23 maternal deaths occurred in the Hospital. Maternal death audits were done as per the Ministry of Health recommendation and none of the findings pointed to errors in the management and care given. The high number of maternal deaths was attributed to Hepatitis E outbreak in the region. Hepatitis E infection causes severe morbidity and high mortality among pregnant women. It was directly responsible for 16 maternal deaths. Ministry of Health was notified about this problem and sent a team to help with the containment of the epidemic. - During FY 2014/15 the HEV epidemic was almost over and therefore the number of maternal deaths reduced. During FY 2015/16 the number of maternal deaths further dropped to just two. The Hospital had two maternal deaths in FY 2017/18. One death was of a mother referred from Kapenguria - Kenya through Amudat Hospital with severe septicaemia following post abortal sepsis, the second was referred from Nakapiripirit District with severe puerperal sepsis and a space occupying lesion (brain abscess) in the brain. All the maternal deaths were audited. The District Health Office and Ministry of Health were informed.

99 of 108 Below Graph 10.4 shows this scenario.

Graph 10.4: Trend of quality indicators over the past five years

Maternal Deaths over 5 years 25 23 20 15 10 7 5 4 3 2 2 0 2013/14 2013/14 2014/15 2015/16 2016/17 2017/18 with HEV without HEV

During FY 2013/14 total still births were 35 out of 1,060 total births. This is equivalent to a still birth rate of 3.3%. Fresh Still births were 21 which is 1.98% of total deliveries. Macerated still births were 14 which is 1.32% of total deliveries. Hepatitis E infection with liver failure contributed to 7 fresh still births. There were 14 FSBs without HEV infection during FY 2013/14. The number of Hospital FSBs was 2 in FY 2017/18.

Graph 10.5: Trend of quality indicators over the past five years

Fresh Still Births 25 21 20 15 14 10 5 2 3 3 2 0 2013/14 2013/14 2014/15 2015/16 2016/17 2017/18 with HEV without HEV

3) Contribution to the HSSP and SDGs The Hospital provides health care services in accordance with the health sector component of the National Development Plan and National Health Policy II. It will strive to achieve the objectives and targets of the Health Sector Development Plan (2016-2020) of Government of Uganda. This continues to guarantee access for all people in its catchment area to basic health services, with special focus on social health protection for vulnerable groups (such as women, children, the elderly and poor). Through its programmes, the Hospital contributes to the attainment of the Health related Sustainable Development Goal of ensuring healthy lives and promoting wellbeing for all at all ages.

100 of 108 The Hospital contributed 18.2% of OPD attendance in the financial year 2017/18 in Napak District. Its role in improving maternal health is markedly significant with 27% of supervised deliveries and 29.1% of antenatal attendance in Napak District having been in Matany Hospital. The Hospital provides free ambulance services to pregnant mothers in labour and sick neonates in Napak District. The prevalence of HIV in Karamoja is increasing from 1.5% in 2006 to the current 3.4%. Matany offers ART services to its clients with 77.3% (475) of clients in the district on ARVs being attended to in Matany Hospital. It also manages 92.2% of tuberculosis cases in the District. It is the only initiation treatment centre for MDR-TB in Karamoja currently with patients coming from all districts of the region except Amudat district. One patient is from Katakwi. The contact tracing and follow up of MDR -TB patients requires a lot of financial resources and a dedicated MDR TB panel. The Hospital has the single intensive therapeutic feeding centre to manage severe acute malnutrition in the district. The Hospital serves as the headquarters of Bokora HSD, supervising 14 lower level health units. The HSD carries out several functions including support supervision for which 138 supervision visits were carried out in 2017/18. It follows up 88 VHTs in Matany Sub County. Since more than 75% of the overall burden of diseases is preventable, Public Health Care remains the major strategy for delivery of health services in the catchment area. Great attention and support is given to health promotion, education, enforcement and preventive interventions such as immunization, promotion of sanitation and nutrition. 4) Sustainability

Matany Hospital sustainability is a very critical and urgent issue. The main threats to sustainability come from the place where we are situated, from National and Global health and economic policies, lack of proper financing of health services, and human resource situation. Provision of health services is continuously increasing each year. This makes it difficult for the Hospital to continue offering subsided services to its catchment population. The sustainability ratio of the hospital in absence of both donors and PHC CG funding last year was 27.46%. The sustainability ratio of the Hospital in absence of donors funding but with PHC CG funding and local revenue in 2017/18 was 54.68%. (Refer to chapter 5). User fees for service this year registered the local recovery/recurrent cost as low as 19.25 %. This clearly demonstrates the dependence of the Hospital on donor funding to continue providing a quality service with low user fees. The poor economic status of the region and general remoteness of the place limits the exploration of other ways of health financing. High unemployment and the few economic activities lead to low household incomes for patients to be able to pay for health services. This makes it unadvisable (because it would compromise our mission of making services accessible to the poor) to increase user fees for service. The Hospital provides private health insurance services for insured patients who are employed by NGOs. These patients pay cost recovery fees. National and Global Policies regarding the creation of new districts and new health centres make service delivery difficult and more cumbersome financially for our hospital. - The PHC Conditional Grant and all other support from government has not matched the increased demand for service added to this component of the HSD which Matany Hospital heads and must partially cover financially. The global economic crisis is having a strong impact on the progressive decline of external donations and considering the high dependence of this Hospital on external donations this becomes of high concern in near future.

101 of 108 The widespread corruption is known to external donors and the withdrawal of support is already a reality which surely will affect health services especially to the most vulnerable people.

Critical Issues:

Requiring local and internal policy  Full cost recovery of services provided especially for patients seeking private services, those referred or self referred from other districts.

Requiring managerial intervention from HSD and District:  Outreaches to hard to reach settlements not availed with basic services  Better coordination at the district of partners involved in health provision in Napak District to ensure that resources are efficiently utilised.  Secondment of Staff or preferably financial contribution to the wage bill of the Hospital  Better planned set up of new health centres. Such that they are built in communities with most need.

Requiring lobby and advocacy and partnership at district level:  Increase financial support in form of grants based on performance  Improvement of access to Hospital by advocating for better and well maintained roads facilitating access of ambulances to health units thus saving lives

Requiring attention/intervention of UCMB  More involvement of PNFP in planning and decision regarding health  Tax exemption issues for medical goods and for generating electricity through diesel generators  NSSF deductions issues regarding expatriates  Secondment or preferably salary payment of Tutors for NMTS and Medical Doctors to hard to reach areas.

Summary of Recommendations:

To Hospital Management:

 Maintain all Hospital and NMTS infrastructure  Diversification of finance sources of the Hospital  Need to continue applying cost recovery of services’ fees structure to patients asking for private services.  Continue effort of identifying and develop essential cadres  Improve departmental supervision in order to guarantee efficient utilisation of resources in the respective departments.  Mentorship of staffs to ensure quality service delivery at all points of health services delivery.

To HSD/District:

 Strive for better cooperation and sharing in planning and resource allocation  Follow referral system and maintain vehicles at H/C’s for transport of emergencies. Vehicles allocated to Health Centres are often out of service  More participation at Board meetings and Hospital activities on the side of District Officials  Hospital to continue participating in district meetings when invited.  The PHC Department in the Hospital must guarantee continued support supervision to the lower level health units in the HSD. Support from the District to continue this delegated service is expected.

102 of 108 To UCMB:

 Liaise with Government on issues of financial constraints and sustainability  Liaise with national insurance agencies on behalf of Expatriates serving in PNFP’s  Build capacity of the Hospitals in the net work to enable them do resource mobilisation. The Catholic Medical Bureau should also inform the various health facilities of the available opportunities at the national and international level, besides policy guidance.  Help to set up technical centres of excellence at hospitals with comparative advantage over others in certain fields. This helps build technical capacity within the network and reduces on cost of maintenance of common equipment among UCMB Hospitals.  Consider bulky/group procurement of some hospital equipment from a single supplier. This reduces cost of buying new equipment by individual hospitals.

To MOH:

 More Support supervision from the Karamoja area team.  More support of PNFP institutions, especially those upcountry with the lowest fees recovery, offering highly subsidised services  Sharing of resources on basis of outputs and performance

Conclusion St. Kizito Hospital operates with one goal: that of making the loving tender touch of Christ for the sick and the poor perceivable here and now, so that they may see, and believe, in Him, their Origin and Destiny. We rejoice with and for all those who have encountered the Lord within the walls of the Hospital; we know that often we have made this encounter more difficult with our shortcomings and fragility: we ask pardon for it. Above everything else, we desire to remain faithful to the task, entrusted to us by the Church, of serving the sick: we are grateful to all those who made and who will make this task possible.

We thank God our Almighty Father for having brought us safely to the end of this Financial Year. A lot more has been achieved and is not documented in this report.

We hope that the contents of this report will help to inform those who worked with us during the year towards the achievement of our mission.

They are:

 the Board of Governors of St. Kizito Hospital - Matany  the Health Authorities of the District and the Country  the Local Government  the Diocesan Authorities

We thank them for having entrusted us with the task of serving the people of Karamoja and of Bokora Health Sub District in particular.

103 of 108 ANNEX 1 - Napak District with Health Units

Lopeei HC III

Ngoleriet Lokopo HC II HC III Matany Hospital Kangole BOKORA HEALTH HC III SUB-DISTRICT Morulinga HC II

Lotome Apeitolim HC III HC II Nakicumet HC II

Namendera HC II Lorengechora HC III Kalokengel HC II

Iriiri HC III

Amedek HC II

Nabwal HC II

104 of 108 ANNEX 2

Members of the Board of Governors: (Following the Constitution of the Hospital)

Voting Members

1. Mr. Paul Abul, Chairman 2. Fr. Denis Olok, Parish Priest, Matany Catholic Church 4. Fr. Achilles Kiwanuka, Provincial Superior of the Comboni Missionaries 5. Sr. Luigina Frison, Provincial Superior of the Comboni Missionary Sisters 6. Sr. Divina Musimire, DHC Moroto Diocese 7. Dr. Pierluigi Rossanigo, Med. Tec. Advisor Moroto Diocese 8. Dr. James Lemukol, DHO Napak District 9. Mr. Joseph Lomonyang, LC V Napak District 10. Mr. Dominic Lochoro, LC III Chairman, Matany Sub County 11. Mr. Alfred Lochap, Sub County Chief Matany 12. The CAO Napak District 13. The Medical Director of Moroto Regional Referral Hospital 14. Mrs. Rose Lowanyang – Representing HSD, Kangole HC III 15. Representative of Hospital (Sister Hospital) 16. Dr. Peter Lochoro, Country Representative of CUAMM 17. Locham Augustine, Staff representative to the board.

Members, holding offices in the Hospital

18. Br. Günther Nährich, Administrator/CEO (Secretary of the BoG) 19. Dr. John Bosco Nsubuga, Medical Superintendent 20. Sr. Hellen Atekit, Ag. Principal Nursing Officer 21. Sr. Nataline Mowo, Principal Tutor of the NMTS 22. Head of the Public Health Department (held by Medical Superintendent)

Members of the Hospital Management Team

1. Dr. John Bosco Nsubuga, Medical Superintendent (Chairperson HMT) 2. Br. Günther Nährich, Administrator/CEO (Secretary of the HMT) 3. Sr. Hellen Atekit, Ag. Principal Nursing Officer 4. Sr. Nataline Mowo, Principal Tutor NTS 5. Head of the Public Health Department (held by Medical Superintendent)

Members on the NMTS Statutory Committee:

1) Fr. Denis Olok, Parish Priest, Matany Catholic Church (Chairperson) 2) Mrs. Rose Lomonyang, DM Kangole HC III (Board Member) 3) The Sub-County Chief, Mr. Alfred Lochap (Board Member) 4) The Assistant DHO Napak District, MCH/Nursing, Sr. Regina Narus 5) The DEO Napak, Mrs. Joyce Nakoya 6) The Diocesan Education Secretary 7) The CEO, Br. Günther Nährich (Ex-officio) 8) The PNO, Sr. Hellen Atekit (Ex-officio) 9) The PT, Sr. Nataline Mowo (Ex-officio)

105 of 108 ANNEX 3

MATANY HOSPITAL ANNUAL FINANCIAL REPORT Actual Cumulative Difference Item cumulative of Description of financial Item last year with last Codes the year FY 2016/17 year FY 2017/18 1XXXX INCOME User Fees' Collection 549,852,350 437,219,908 112,632,442 PHC Conditional grants to Hospitals 444,975,777 518,675,384 - 73,699,607 PHC Conditional grants to School 40,716,772 17,664,533 ( HTI - Non - wage ) 23,052,239 Other School Income (incl. Sch. fees) 260,128,000 159,185,050 100,942,950 PHC Conditional grant for HSD ( Non- 32,000,000 34,578,359 - 2,578,359 wage ) Donations of funds/goods for capital 428,869,753 54,008,341 374,861,412 development Donations of funds for recurrent cost 1,195,573,905 1,174,081,015 21,492,890 Donations of goods and services 166,929,588 96,719,044 70,210,544 Value of Drugs received through EDP 35,695,082 17,225,000 18,470,082 (in kind) Value of Lab. Reagents & 8,967,960 - 8,967,960 Consumables received (in kind) Income for projects(HIV/Aids, Malaria, P 96,719,044 - 96,719,044 Tuberculosis etc) Other Income 234,470,445 318,679,727 - 84,209,282 TOTAL INCOME 3,389,211,671 2,939,111,071 450,100,600 EXPENDITURES: 21 EMPLOYMENT COST 211101 Staff Salaries and wages 1,071,137,254 976,162,006 94,975,248 211103 House/bicycle/overtime & other all. 32,914,900 18,211,000 14,703,900 211103 Night/safari all. 8,715,900 13,595,200 - 4,879,300 211103 Duty/Resp./Acting all. 42,705,700 30,835,000 11,870,700 211103 Lunch all. 63,758,000 60,653,000 3,105,000 211103 Cost for interns 211103 Cost for student field trips under NTS Exp. 1,156,000 - 1,156,000 212101 XXX NSSF XXX 92,255,633 90,934,835 1,320,798 212101 P.A.Y.E 83,284,952 73,774,471 9,510,481 Staff health/ Social Health Insurance 213001 14,343,200 15,347,432 - 1,004,232 (Medical expenses) Incapacity, death benefits & funeral 213002 450,000 830,000 - 380,000 expenses Retrenchment cost / Licence and Staff 213003 4,216,587 4,702,500 - 485,913 Insurance Sub Total 1,413,782,126 1,286,201,444 127,580,682

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ADMINISTRATION COSTS FY 2017/18 FY 2016/17 Difference 221001 Advertising and Public Relations 1,481,000 3,087,500 - 1,606,500 221002 Workshop/seminars 670,000 3,776,000 - 3,106,000 221003 Staff training - 221004 Recruitment cost - 221005 Hire of venue - 221009 Welfare & Entertainment 15,393,550 9,905,800 5,487,750 221011 Printing and stationery 62,066,983 55,885,992 6,180,991 Other office expenses (small office 221012 517,500 204,274 313,226 equipment ) 221013 Bad debts - 221014 Bank charges 3,842,880 2,424,536 1,418,344 221015 Financial & related costs - Information Financial Management 221016 - System Recurrent cost 221017 Subscription 850,000 6,944,000 - 6,094,000 221018 Exchange loses / ( gains) - 222001 Tel./fax./postage/courier 1,925,450 13,415,000 - 11,489,550 Information and communication 222003 6,570,147 9,450,000 - 2,879,853 technology (ICT) 223004 Guard and security services - 224002 Uniforms & protection clothing 9,173,065 5,705,818 3,467,247 225001 Consultancy charges 450,000 4,070,000 - 3,620,000 227001 Transport all. - Sub Total 102,940,574 114,868,920 - 11,928,346 PROPERTY COST 223001 Cleaning of ward/dormitories 64,233,258 61,089,733 3,143,525 223001 Cleaning/slashing of compound - 223005 Electricity 35,612,774 32,400,003 3,212,771 223006 Water - 228001 Repairs and upkeep of buildings 59,695,566 3,451,000 56,244,566 223xxx Rents and rates - Sub Total 159,541,598 96,940,736 62,600,862 TRANSPORT AND PLANT COST 226001 Insurance for vehicles - License for property, vehicles , 226002 2,035,000 2,142,000 - 107,000 equipment etc 227002 Air travel - 5,608,300 - 5,608,300 Carriage, Haulage, Freight & Transport 227003 33,626,620 2,380,671 31,245,949 Hire 227004 Fuel 77,530,780 37,141,136 40,389,644 228002 Maintenance and repairs - 228002 Tyres and spares 26,408,920 19,416,000 6,992,920 228003 Operation/maintenance of generators 35,914,580 38,261,740 - 2,347,160 Sub Total 175,515,900 104,949,847 70,566,053 SUPPLIES AND SERVICES 221007 Newspapers and publications - 221008 Computer Supplies 9,849,500 8,500,000 1,349,500 228004 Maintenance of equip. and supplies 2,130,000 550,000 1,580,000 22xxxx Equipment and supplies - Sub Total 11,979,500 9,050,000 2,929,500

107 of 108 MEDICAL GOODS AND SERVICES FY 2017/18 FY 2016/17 Difference 223007 Foodstuff and firewood 72,158,521 46,383,780 25,774,741 224001 Medical drugs 317,742,391 258,565,369 59,177,022 224001 Drugs received through EDP (in kind) - Value of Lab. Reagents & 224001 58,912,788 110,047,100 - 51,134,312 Consumables received (in kind) 224002 Beds and beddings 9,173,065 9,173,065 Maintenance of medical tools and 228004 - - equip. Donations of goods and services ( by 282101 - hospital ) 22400X Medical supplies 330,120,397 260,294,824 69,825,573 224xxx Medical tools and equipment 109,044,543 22,432,035 86,612,508 Sub Total 897,151,705 697,723,108 199,428,597 PRIMARY HEALTH CARE Support supervision (together with Xxxx - outreaches) Xxxx Outreach services 44,055,200 23,994,600 20,060,600 Xxxx Drugs & sundries for LLUs 5,141,305 9,456,834 - 4,315,529 Xxxx Planning and meetings - - Xxxx Training of TBAs - - Xxxx Hospital Based PHC 33,098,230 33,098,230 Sub Total 82,294,735 33,451,434 48,843,301 CAPITAL DEVELOPMENT 311101 Land - Major maintenance and upkeep of 312101 144,332,853 121,988,208 22,344,645 buildings 312102 Residential building - Transport Equipment ( motor vehicles, 312201 - motorcycles ) 312202 Machinery & Equipment (non-medical ) - Medical Equipment (eg Precision & 312202X - optical equip etc) 312203 Furniture & Fittings 694,502 - 694,502 Cultivated Assets (Breeding stock -fish 312301 - & poultry, diary cattle etc) Depreciation (all categories) ( this can 231XXX - placed under expenses category ) Other capital expenditure / 231007 - Depreciation cost Staff Development costs (see page 4 221003 95,778,950 104,289,550 - 8,510,600 for definition) Sub Total 240,111,803 226,972,260 13,139,543 TRAINING SCHOOL TOTAL ANNUAL

COST (see explanations) Sub Total 244,175,161 193,136,286 51,038,875 TOTAL EXPENDITURE TOTAL 3,327,493,101 2,763,294,035 564,199,066

Balance (Income less Expenditures) 61718,571 175,817,036 - 114,098,465

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